Music and Movement Class

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Kiel Recreation Department

Music and Movement Class Friday Mornings June 22-August 17 (no class July 13) 1 to 2 year olds 8:45-9:15 am 3 to 5 year olds 9:30-10:00 am Held at Kiel Community Center (Lower Level) $16.00 per child Name ______________________

Age ______

Address ____________________

City ____________

Zip code ____________________

Phone # ____________________

Email ______________________ I hereby acknowledge that the City of Kiel disclaims liability for, and I agree to specifically hold them harmless from theft, property loss, damages, or personal injury sustained by me on the premises and arising out of the above class. I hereby agree to save harmless and indemnify them from any and all expenses arising because of any claim which hereafter may be presented as a result of the above class. I also grant full permission to any and all of the foregoing to use any photographs, video tapes, motion pictures, recordings and any other record of this event for any legitimate purpose. I have no medical or physical condition in which this class would be against my doctor’s recommendation. The Kiel Recreation Department has the right to cancel my registration or refuse any admission when it may be deemed necessary. All fees are non-refundable. We are not responsible for any child before, during, or after class time.

Date: ____________

Parent/Guardian signature:______________________ Please return this form and payment to: The Kiel Community Center Attn: Missy Brandt 510 3

rd

Street Kiel, WI 53042 920-894-7861