Please print this form and mail it along with a check (made out to The Happy Bookworm, Inc.):

The Happy Bookworm, Inc.
P.O. Box 376
Syosset, NY 11791

Class Location:  ___________________________________________

Class Day:  _____________________________

Class Time: ____________________________

Class Price:  ____________________________

Child's Last Name _________________________________________

Child's First Name _________________________________________

Child's Birthdate   __________________________________________

Address  _________________________________________________

_________________________________________________________

Home Phone Number________________________________________

Emergency Contact Number __________________________________

Cell Phone Number__________________________________________

Mother's Name ____________________________________________

Father's Name _____________________________________________

Email Address _____________________________________________

Does your child have any allergies?

_________________________________________________________

If you are signing up with a friend, please write his/her name here:

________________________________________________________


Please choose one of the following and sign:

_____ I give permission for my child's photo to appear in the pamphlet or on the website for The Happy
Bookworm, Inc.

_____ I DO NOT give permission for my child's photo to appear in the pamphlet or on the website for The
Happy Bookworm, Inc.

___________________________________                                    
Signature &  Date

We will contact you by email or phone to let you know that we have received your registration and
payment.
1.  Students will be
registered on a first come
first served basis.

2.  If for some reason you
need to cancel the session,
the following fees will apply.  
There will be a $25
cancellation fee for canceling
prior to the first class.  There
will be a $50 cancellation fee
for canceling prior to the
second class.  There will be
no refund after the second
class.

3.  The Happy Bookworm,
Inc. has the right to cancel
any class based on limited
enrollment.  If a class is
canceled, all tuition and fees
will be refunded.

4.  The accompanying adult
is solely responsible for the
safety of his or her child or
child committed to his or her
care while at The Happy
Bookworm, Inc.  The Happy
Bookworm, Inc. and its
employees will be held
harmless for any accident or
injury to all adults and
children participating in
activities in The Happy
Bookworm, Inc.