Distance Learning Registration - Yoga and Zumba

Student Registration Form

Fill out the form carefully for registration
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
E-mail
Phone Number

Area Code Phone Number

Early Bird Registration (ends this Sunday 4/12/2020)

Yoga (Mondays 3pm) - Early Bird Price $ 100.00

Zumba (Wednesdays 3pm) - Early Bird Price $ 100.00

Yoga & Zumba $ 200.00

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Additional Comments
Should be Empty: