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Early Childhood Mommy and Me

Mommy & Me Registration

Mommy & Me will be led by Chaya Mushka Wuensch!
1. Child/ren’s Information
Child 1*
First NameLast Name
Birth Date*
MonthDayYear
Gender*
MaleFemale
Sessions ($15 per session)
Tuesday 12/29Tuesday 1/5Tuesday 1/12Tuesday 1/19Tuesday 1/26
2. Parents information
Phone Number*
Area CodePhone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's Name
First NameLast Name
Cell Phone
Area CodePhone Number
E-mailPrimary email
Father's Name
First NameLast Name
Cell Phone
Area CodePhone Number
E-mailPrimary email
How did you hear of us?
4. Payment Information
Amount
$15$30$45$60$75
Total
$0.00
Comments
I would like to receive news and updates by email

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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