Fall 2010 Registration

Twice a week for 16 weeks PAY IN FULL.

Child’s Name * First Last
Date of Birth * MM / DD / YYYY
Gender *
Boy Girl
Parents’ Names * First Last
Email *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Home Number ###-###-####
Cell Number * ###-###-###
Work Number ###-###-####
School Attending Fall ’10
Grade Enrolled Fall '10
Emergency Contacts
Phone Number ###-###-####
Allergies/medical conditions
How did you hear about Early Einsteins?
Select prefered days from the following.
Please list your 3 preferred times from the schedule HH : MM : SS AM/PM
HH : MM : SS AM/PM
HH : MM : SS AM/PM
In consideration of your accepting this registration, I, the parent or guardian of the above named student, hereby give my consent and agree to release and hold harmless Early Einsteins of Newport Beach and any of their directors or instructors from any liability, claim, or action for personal injury and/or property damage resulting from, arising out of, and/or connected to the child's participation in Early Einsteins classes or special events.I am committing to the entire session and agree to pay the full tuition. If my child is absent from a class it is my responsibility to schedule a make-up class if available. *
I agree