first name last name gender birthday (MM/DD/YY)

first name last name phone (cell/work/home) relationship to child








Previous language/culture exposure. Give us as much detail as possible.

How did you hear about us?


Name of physician

Physician phone

Physician's address

Additional medical info
*Please list any known allergies, medical conditions, information or anything else you would like Mi Manzana to know.

Best number to reach you or your designated caregiver in case of an emergency:

Please note that it is your responsibility to keep your child’s medical information and emergency contact information up-to-date, notifying Mi Manzana of any changes as soon as they occur.


Fees for all classes are set on a class-by-class and program-by-program basis. *All fees are payable in full at the time of class registration. If payment is made at our location in-person, cash, personal check (made payable to Mi Manzana Education LLC) and credit card are accepted. Visa, MasterCard or American Express are accepted on-line.

Refunds will be granted for cancellations prior to the first class. A prorated refund will be given for cancellations made after the 1st class. All refunds for classes will be less a $50 cancellation fee per child per session. No refunds will be granted for cancellations made after the 2nd class.

There shall be no make-up classes permitted.

In its sole discretion, Mi Manzana reserves the right to cancel or modify classes and programs, and/or make changes to instructors and staff. We will refund 100% of the payment if Mi Manzana cancels/modifies schedule and child cannot attend anymore.

Drop-offs and Parent/Caregiver Presence
All classes and programs for children require the presence of the child's parent or approved caregiver in class or on the premises where classes are held if child is 4 years old or younger. When parent or caregiver is attending class with the child, there is a limit of 1 parent/caregiver per child in classrooms. If a child is being dropped off for class, the parent/caregiver shall be reachable by phone and available to quickly return to the facility if that’s why you want. Children enrolled in drop-off classes must be escorted to and from the classroom by the parent/caregiver. Parents are solely responsible for their children and the caregivers selected by them to care for their children while attending Mi Manzana.

Policies and Procedures (subject to change at any time).
- Please do not bring children to Mi Manzana when they are ill or have a medical condition that is communicable. We reserve the right to restrict admission and/or send a child home, when, in our opinion that child is ill or risks the health or wellbeing of other children.
- While present at Mi Manzana or participating in Mi Manzana classes, parents/and/or caregivers assume full responsibility for their own conduct and that of their children in attendance. All members, parents and caregivers are responsible for their child's supervision and safety while in class, unless such activities are supervised by Mi Manzana as part of a drop-off class where such parents and/or caregivers are not present.
- All parents, caregivers and their children shall behave and conduct themselves in ways that do not threaten health, well-beong and full enjoyment of the class to other parents, caregivers and their children.
- In an effort to provide a safe and fun environment as possible, Mi Manzana prohibits food, drinks and gum in the classroom, with the exception of food provided by teacher. Mi Manzana is food allergy aware, any foods containing nuts or nut ingredients are strictly prohibited. Foods made in plants that process nuts, nut ingredients, oils or other derivatives of nuts may be found in foods used in recipes used in one of our cooking classes. We ask you to please be extra aware of these circumstances.
- Strollers are not permitted beyond the entrance, please use space right outside the building.
- Mi Manzana is not responsible for any personal belongings

Revocation of Enrollment
Failure to observe the above policies and procedures of Mi Manzana as determined by Mi Manzana in its sole discretion, result in your child’s removal from the program without refund.

Assumption of Risk, Release, Waiver and Indemnification
The parent/caregiver of children in attendance at Mi Manzana hereby acknowledges, agrees and accepts the risk of injury and illness inherent in activities, classes and programs involving children, such as, particularity, the classes offered by Mi Manzana. Such risks may include but are not limited to injuries from falling, bumping, abrasions, scrapes, cuts, burns, sprained or bruised limbs, as well as risk from the actions or omissions of others. Such risks may include illnesses and conditions transferable between persons. PARENTS ARE SOLELY RESPONSIBLE FOR THEIR CHILDREN AND THE CAREGIVERS SELECTED BY THEM TO CARE FOR THEIR CHILDREN WHILE ATTENDING MI MANZANA.

As such, each parent and caregiver hereby releases and discharges Mi Manzana Education, LLC, its members, owners, directors, officers, affiliates, contractors, agents, employees, successors and assigns, from any and all injuries, illnesses, medical conditions, damages, claims, liabilities, expenses or judgements, including attorney's fees and court costs, suffered by them or by their children as a result of their attendance, and their child's attendance, at Mi Manzana classes. Furthermore, each parent, caregiver shall indemnify and hold harmless Mi Manzana Education, LLC, its members, owners, affiliates, contractors, agents, employees, successors and assigns, against any and all injuries, illnesses, medical conditions, damages, claims, liabilities, expenses or judgements, including attorneys' fees and court costs resulting from any negligent, grossly negligent or deliberate act or mission of the parent, caregiver or child in attendance. The above release and indemnity shall not apply to the extent an injury or illness is caused by the act or omission of a Mi Manzana employee which is either grossly negligent or intended to cause such injury or illness.

Caregivers and parents expressly agree that Mi Manzana may use photos taken of such persons or their children for archival, promotion and publicity purposes.

As a Mi Manzana class participant you will be added to our newsletter list so that we can keep you updated on Mi Manzana's latest offerings, discounts and events.

Indicated in the space above are any health problems or conditions of which the school should be aware (such as allergy, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and my child, knowingly and voluntarily accept that risk. I, the undersigned, for myself, my heirs, administrators, and executors, herby waive and release Mi Manzana Education, LLC and i embers,owners, directors, officers, affiliates, contractors, agents, employees, successors and assigns from any and all claims or damages of any kind arising out of my child’s participation in the program of Mi Manzana Education, LLC. I further certify that the aforementioned student is in proper physical condition to participate in the program and that he/she has been examined by a licensed physician and found to be in proper physical condition to participate in said program. I, the undersigned, do herby authorize Elena Simpser or her designated agents (being teachers or administrators employed by Mi Manzana Education, LLC) to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorize the treating physician to provide such emergency medical services. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make Mi Manzana Education, LLC responsible for payment of medical expenses. This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect for one year from the date signed below.

I Agree

D. Billing
Click here to pay online or you can also bring a check the first day of classes made payable to Mi Manzana Education LLC.