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.