SUMMER  REGISTRATION FORM

LAST NAME____________________    HOME PHONE (        )______________

First Names:          Bday    School           CELL PHONE (        )_____________

_____________  __/__/___  _______

 _____________ __/__/___   ______     Email __________________________

_____________ __/__/____  ______   OK to Use for: ? schedule changes ? future info

ADDRESS___________________________ TOWN_____________ ZIP______

In case of emergency (if no one answers at home phone or cell): Please give 2 additional phone numbers with  name:

____________________________    __________________________________

Special info for allergies, special needs, physical restrictions, (or call to discuss): ________________________________________________________________

1^st Name      CLASS TITLES            Location    DATE(s)      TIME        TUITION

___  __________________________  ___   __________   _________  $______

___  __________________________  ___    __________   _________  $______ 

___  __________________________  ___    __________   _________  $______                 

___  __________________________  ___    __________   _________  $______                 

___  __________________________  ___    __________   _________  $______

___  __________________________  ___    __________   _________  $______                 

___  __________________________  ___    __________   _________  $______

___  __________________________  ___    __________   _________  $______                  

 Additional classes may be listed on separate piece of paper or phoned in later     

PAYMENT: by Check #____ Payable to Kaleidoscope                  TOTAL $______

by:__ Visa __M/C Exp Date___/___ Account #______ ______ _______ ______*

 Add 50¢/class convenience fee* on charges = # classes____x50¢ =$_____                   

WAIVER AND RELEASE OF ALL CLAIMS

   I do hereby fully release and discharge Kaleidoscope Children’s Center, Inc., its officers, agents, servants and employees from any and all claims from injuries, damage or loss which I (or dependents under 18 years of age) may have or which may accrue to me (or dependents) on account of my (their) participation in the above Kaleidoscope Children’s Center, Inc. sponsored activities.

   I further agree to indemnify and hold harmless and defend Kaleidoscope Children’s Center, Inc. its officers, agents, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me (or dependents under 18 years of age) and arising out of, connected with, or in any way associated with these activities sponsored by Kaleidoscope Children’s Center, Inc.

                       PARENT SIGNATURE_____________________________ DATE_______

MAIL Form to: KALEIDOSCOPE 1500 Walker St., W Springs, IL 60558 or

FAX (630)655-6624 PHONE (708)246-9699 EMAIL KscopeClasses@yahoo.com

 FALL and SPRING REGISTRATION FORM

LAST NAME____________________    HOME PHONE (        )______________

    First Name       B’day       School     CELL PHONE (        )__­____________

______________ __/__/___  _______      

______________ __/__/___  _______    Email _________________________

______________ __/__/___  _____ OK  for use to: __ schedule changes __ future info

ADDRESS___________________________ TOWN_____________ ZIP______

In case of emergency (if no one answers at above home or cell): Please list 2 names & phone numbers for emergency contacts:  ______________________________   _________________________________

Special info regarding allergies, special needs, physical restrictions, etc.:

________________________________________________________________

Child’s      CLASS TITLE           Location     DAY  TIME       Which  Paymt Amt

1^st Name                                                                                  Session    Included

              Choice                                                                                     (circle)

______ 1^st __________________   _____    ____  _______  Fall Spring $______

             2^nd__________________   _____    ____  _______

              Choice

______ 1^st __________________   _____    ____  _______  Fall Spring $______

             2^nd__________________   _____    ____  _______

              Choice

______ 1^st __________________   _____    ____  _______  Fall Spring $______

             2^nd__________________   _____    ____  _______

              Choice

______ 1^st __________________   _____    ____  _______  Fall Spring $______

             2^nd__________________   _____    ____  _______

              Choice

______ 1^st __________________   _____    ____  _______  Fall Spring $______

             2^nd__________________   _____    ____  _______

          Additional classes may be listed on separate piece of paper.

$35 non-refundable partial tuition payment required for each 1^st choice/session.

Bal. due 30 days prior to class start. $10 transaction fee/class for Visa/MC_____*

METHOD OF PAYMENT:                                                                      TOTAL $______*

__ Check #______ Payable to Kaleidoscope                                                                                             

__ Visa __M/C Exp. Date___/___ Account #_______ ______ _______ _______*

WAIVER AND RELEASE OF ALL CLAIMS

   I do hereby fully release and discharge Kaleidoscope Children’s Center, Inc., its officers, agents, servants and employees from any and all claims from injuries, damage or loss which I (or dependents under 18 years of age) may have or which may accrue to me (or dependents) on account of my (their) participation in the above Kaleidoscope Children’s Center, Inc. sponsored activities.

   I further agree to indemnify and hold harmless and defend Kaleidoscope Children’s Center, Inc. its officers, agents, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me (or dependents under 18 years of age) and arising out of, connected with, or in any way associated with these activities sponsored by Kaleidoscope Children’s Center, Inc.

                                PARENT SIGNATURE_________________________ DATE_______

 RETURN FORM TO:  KALEIDOSCOPE 1500 Walker St, W Springs, IL 60558 

or FAX Form: (630) 655-6624  or PHONE: (708) 246-9699