Creative Movement
Online Sign-up Form


Children's names and ages:
	Name	Age





Parent/Caregiver name:

	Will attend sessions with child? Yes No

Special needs or accommodations for child.


Other comments or suggestions.


Contact information:
Name:
Mailing address:

Phone:
E-mail:

Payment: $15 per child per six-week session.
	Check Enclosed Will pay at first session Fee waiver requested One-time $2.50 discount per child for Winter 2008 participants	Amt: $
Enter Security Code:

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