Rally Class Payment Form
This form is ONLY for students currently enrolled in classes with Samantha at SICDTC or pre-approved by registrar/instructor
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Dog's Name (if Multiple Dog's Add in Comments below)
*
Start Date of Session & Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Comments or Multiple Dog Information
Choose ONE option below: If you have club vouchers please contact Desma (sicdtc@hotmail.com) to get a coupon code
*
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Rally Class Non-Member
8 week classes with instructor Samantha Scicchigno
$
215.00
Quantity
1
2
3
4
Item subtotal:
$
0.00
Rally Class Member in Good Standing
8 week class with Instructor Samantha Scicchigno
$
145.00
Quantity
1
2
3
4
Item subtotal:
$
0.00
Rally Class Member TC Discount ONLY
8 week class with Instructor Samantha Scicchigno
$
125.00
Quantity
1
2
3
4
Item subtotal:
$
0.00
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
Submit
Should be Empty: