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.
