Heart Prints Center for Early Education Online Registration

Registration

Already a customer? Click here to login.

Sorry, but this class is no longer available.

Welcome to Heart Prints Center for Early Education! Please complete the following registration form.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info
(Not Contact #1 or #2)

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Skill Notes

Please click on the Search button below, then choose the class.

Request Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Skill Notes

Please click on the Search button below, then choose the class.

Request Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Skill Notes

Please click on the Search button below, then choose the class.

Request Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Skill Notes

Please click on the Search button below, then choose the class.

Request Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Skill Notes

Please click on the Search button below, then choose the class.

Request Classes

Select Class

Add Another Student

Required Policies and Agreements

Payment Policy

Tuition is due on the first day of the month prior from September forward. Tuition not submitted by the 10th of the month will accrue a $5 late fee per day until tuition is received.

Accounts that are a month behind in payment may result in the termination of service. Students will not be allowed to return to school until balances are paid.

A one-month written notice is required prior to withdrawing a student. Tuition pre-paid beyond one month will be refunded. Pre-paid tuition will not be refunded if proper notice is not given.

All balances must be paid in ful prior to the last day of school. Outstanding balances may be referred to a collection agency. All fees associated with collections or attorney charges will be added to the collection amount.

I've read the above and agree.

Cancellation Policy

Classes are subject to a minimum and maximum enrollment. In the event of our cancellation, Heart Prints Center will attempt to notify you in advance and offer you another selection. Missed classes WILL NOT be refunded or credited. Any changes must be approved by Director or Assistant Director of Heart Prints Center.

I've read the above and agree.

Photography Release

I understand that the staff of HeartPrints Center for Early Education will take photographs of my child during classes and on field trips throughout the year.

These photographs may be used to share with parents directly, share with other families within Heart Prints, used for marketing and advertising, and social media.

No email copies of class photographs will be distributed to parents unless their child is the only child depicted in the photographs or unless all parents of the children in a photograph have given their permission for email distribution.

No photographs of children attending Heart Prints will be released to news media or used for purposes other than those mentioned within this release form without the expressed written permission from the parents.

I've read the above and agree.

Yoga Liability Waiver & Intake Form for Children

I hereby agree to the following:

My child has permission to attend a yoga class at Heart Prints Center for Early Education.

My child is participating in classes or services during which she/he will receive information and
instruction about yoga and health. I recognize that yoga requires physical exertion, which may be
strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I
understand that it is my responsibility to consult with a physician prior to and regarding my child's
participation in any physical fitness program, including yoga. I represent and warrant that my child
has no medical condition that would prevent her/his participation in physical fitness activities.

In consideration of being permitted to participate in the yoga classes, I agree to assume full
responsibility for any risks, injuries or damages, known and unknown, which my child might incur as a
result of participating in the program. In further consideration of being permitted to participate in the
yoga classes, I knowingly, voluntarily, and expressly waive any claim I may have against the yoga
instructor, Heart Prints Center for Early Education, or The Regional Learning Alliance for injuries or
damages that my child may sustain as a result of participating in classes or workshops held at
Common Ground.

If my child participates in other gross motor activities or events at Heart Prints Center for Early
Education (such as dance, martial arts, gross motor play outside, gross motor play inside etc.) I will
also assume full responsibility for any injuries that may result from her/his participation, participation, with the same considerations that this waiver stipulates for yoga.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number