Registration Form
Please fill out completely. Respond with N/A to any fields that do not apply.
Email *
Name of class/activity *
How did you hear about us? *
Child's First and Last Name *
Age *
Guardian First & Last Name *
Guardian's Cell Phone # *
Preferred Email Address *
Primary Emergency Contact Name & Relation to child *
Primary Emergency Contact Phone # *
Allergies/Special Health Conditions *
Photographic and Video Release
I hereby give Motor Mouth Therapy Services, the absolute right and permission to take, copyright, use, and publish any photographs or video of or concerning my child for the purpose of any MMTS advertising, education, promotion, or other purpose consistent with the MMTS mission. I agree that any such photograph or video is the exclusive property of MMTS, and I hereby waive all rights thereto. I further waive any and all rights to inspect and/or approve any printed material that may be used in conjunction with the photographs or video, or to approve the use to which the photographs or video may be applied. *
Release of Liability
I acknowledge that there is always a risk of injury with any physical activity. I hereby, intending to be legally bound, waive forever all claims for damages against MMTS the owner(s), and the employees/therapists for any and all injuries and losses, including theft, loss of property, or death that I, my son, daughter, or ward may sustain while participating in any and all activities at MMTS. *
Payment, Cancellation and Late Pick up
Payment is due upon registration. If given a 48-hour notice, we can switch your pre-paid registration to a future date. Sorry, no refunds are given. If child is not picked up on time, there is a $15 charge for the first 15 minutes past class time. $2 per minute for each additional minute after 15. *
By signing this form, I acknowledge that I have read and understand the contents and am competent to execute it, or if executed on behalf of another, that I am authorized to execute it on the behalf of that person. By checking 'I Agree', you are signing this form electronically and you agree that your electronic signature is the equivalent of your manual signature on this form. *
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