Summer 2017 Secure Online Registration Form

This form is protected by 128 Bit Secure Socket Layer Technology

* indicates required field

Child's Name

*First Name *Last Name

*Birthday (mm/dd/yy) *Gender

Parent/Caregiver Information

*First Name *Last Name

First Name Last Name



*City State *Zip

*Home Phone

Cell Phone 1

Cell Phone 2

Work Phone


If someone else will be bringing your child to class, what is his or her name?

Name Relationship

*Please select a class and time:

*Please select an alternate class and class time, in the event that your first choice is unavailable:

*Materials option: would you prefer CDs, or digital download? (more information here)

*Is your family new to our studio, or returning?

If you are new to our studio, please tell us how you found out about us, or whom we may thank for referring you:

If your child attends a school or pre-school, what is the name of that school?

What are the names and birthdates of any siblings of your child?

Name Birthday (mm/dd/yyyy)

Name Birthday (mm/dd/yyyy)

Name Birthday (mm/dd/yyyy)

Name Birthday (mm/dd/yyyy)

What is the musical background of your family (list any instruments played)?

Please tell us any other information about your child that might be helpful (allergies, learning challenges, likes/dislikes, etc.)

*We're sorry to have to ask this, but we need to make sure that you are a human ;-)
Please type in the answer to the following question, answering with a single digit: what is five plus three?

Payment Arrangements:

to our mailing address: East Dallas Childrens Music, c/o 942 Bridget Ln, Dallas, TX, 75218

By clicking on the "Submit" button, acknowledge that I have read and understood the East Dallas Children's Music policies and agree to the terms within. I wish to register my child for the class indicated. I understand that photographs taken in class may be used without financial compensation, unless otherwise indicated in writing. Submission of this registration indicates my agreement that I will not hold East Dallas Children's Music responsible for any loss, damages or injury incurred directly or indirectly from participation in the East Dallas Children's Music program or class. If paying by credit card, submission of this registration also constitutes authorization to charge said card.