Parent(s)
Name of Adult(s) Attending (if different)
Address
City State Zip
Email
Home Phone Cell Work
I prefer to be contacted by Email Regular Mail

Child #1 Name Date of Birth
Child #2 Name Date of Birth
Child #3 Name Date of Birth

Class Choice
1st Choice: Day Time Location Select one New Paltz Poughkeepsie Stone Ridge
2nd Choice: Day Time Location Select one New Paltz Poughkeepsie Stone Ridge
3rd Choice: Day Time Location Select one New Paltz Poughkeepsie Stone Ridge

Tuition (check all that apply)
$15 Registration Fee (for families new to MHMT only)
$175 First Registered Child
$115 Sibling of a Registered Child
Free Second Sibling of a Registered Child
Free Infant Sibling of a Registered Child (born after 1/27/10)
Total Amount Due

Method of Payment
Check enclosed (payable to Mid-Hudson Music Together LLC)
Visa Mastercard
Card # Expiration Security Code (last 3 digits on back of card)

Signature _____________________________________

How did you hear about us?
Print and send this form with payment by September 19th to:
Mid-Hudson Music Together LLC
PO Box 508
Rosendale NY 12472

Mid-Hudson Music Together LLC is licensed by Music Together LLC - www.musictogether.com.