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Fall / Winter 10 Mini-Session
On-Line Enrollment
How did you learn about
Kindermusik with Lori Burkhardt?
Check as many as apply.
Parent/s Name/s
(First & Last)
(helpful to have both
when I have to call Home)
1st CHILD INFO
2nd CHILD INFO
Questions? Comments?
Mailing Address
Street
City, State ZIP
Home Phone
Cell Phone - indicate MOM or DAD
Other phone - indicate who this belongs to
email address
for educator only, will NOT be shared
First (Nickname?) & Last
Boy or Girl?
Birthdate
1st choice LOCATION/DAY/TIME
Does your 1st child have any special needs that the teacher should be aware of?
First (Nickname?) & Last
Birthdate
Boy or Girl?
Does your 2nd child have any special needs that the teacher should be aware of?
Caregiver NAME, ADDRESS, PHONE, EMAIL if bringing child to class
Work Phone - indicate MOM or DAD
By clicking SUBMIT...
You agree you are enrolling your child/children
for the 4- OR 8-lesson KM Mini-Session You agree you are responsible for the full tuition + materials.
You agree to abide by the policies/fees of Kindermusik with Lori Burkhardt.
More children to enroll?
Just submit another form with that child's info,
and I will see that it is the same family.
Sibling/s age/s not enrolled
PLEASE NOTE: None of your information will be shared w/any party.
It will only be used by Kindermusik with Lori Burkhardt.
I plan to by with (check as many as apply):
2nd Choice
LOCATION/DAY/TIME
1st choice LOCATION/DAY/TIME
After filling in Form, click SUBMIT at the bottom of the page. The Form will be sent to Lori through email. After you click the SUBMIT button, you will receive a Confirmation Message, then please click BACK. The site will return to this page so you can mail check payment or pay with PayPal.
IF PAYING BY PAYPAL
put in your TOTAL and then click "Update Total" then put in your personal info. Please be sure you are paying the TOTAL of TUITION + MATERIALS (the materials are different for EACH SEMESTER)
(check payment preferred as PayPal charges me fees)
IF PAYING BY CHECK
Lori Burkhardt (check to ME please,
NOT 'KM with Lori' as the bank will NOT accept it)
(check payment preferred as PayPal charges me fees)
1286 Weatherby Dr
St Louis MO 63146
H / O ~ 314.692.8032
2nd Choice
LOCATION/DAY/TIME
Payment by PayPal or check MUST be received
within 5 business days, otherwise,
your Enrollment will NOT be processed.
Kindermusik with Lori Burkhardt
Licensed Educator 1995
Kindermusik Maestro since 2007
H / O ~ 314.692.8032
www.KMwithLori.com
