Group Winter Session

Group Winter Session Registration

January 10th-February 19th (6 weeks)
**A $30 enrollment fee is required for new students. You can pay this through paypal or by check.**
Please select the days you are available: *

Monday Tuesday Wednesday Thursday Friday Saturday (MORNING ONLY)
Lessons per week *

One: $570 for 6 lessons Two: $1,140 for 12 lessons
Student Information
Student's Name *

First Name Last Name
Birth Date *

Month Day Year
Gender

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
Name *

First Name Last Name
Cell Number *
E-mail *
example@example.com
Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship
Phone Number *
Alt. Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe. *
Is the student prescribed an inhaler? If yes, please explain any instructions. *
New Student Enrollment Fee *
prev next ( X )
Pay with PayPal
$ 30.00

Pay with check Add $30 to you session total
Free

Total

$ 0.00
Should be Empty:

Group Winter Session Registration