Yes! I want to register
Child's Name   Child's Hebrew Name
Child's Age   Child's D.O.B.
Mother's Full Name   Mother's Religion
Father's Full Name   Father's Religion
Address   Apt.
City, State, Zip
City              State               Zip 		  Home Phone
Mother's Cell Phone   Father's Cell Phone
Email   Facebook Name*
      *To see updates on info and schedules.
Is there any information concerning your child that is important for the directors to know?
(ex: asthma, food allergies)
Do you give permission to use photographs of your child in print materials, on our website, emails and
facebook? Yes No
How did you hear about Mommy & Me?
 
PAYMENT PLAN
My child will attend classes for $12 /Class   
I understand that by submitting this form I am committing to pay the above outlined fees.
Name:   Date: