A Chance to Dance
Fill out the form carefully and sign up each participant.
Class Date
December, Friday 6th - 5:00 - 6:00 pm
Class Date
December, Friday 13th, 5:00 - 6:00pm
Class Date
December, Friday 20th, 5:00 - 6:00pm
Class Date
December, Friday 27, 5:00 - 6:00pm
Class Date
August - Friday 31st 5th 5:00 - 6:00 pm
Class Participant Name
*
First Name
Last Name
Gender
*
Male
Female
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Age
*
Ethnicity
*
Hispanic/Latino
African American
Asian
White Caucasian
Other
City where you live
*
Family/Parent/Guardian Name
*
First Name
Last Name
Number in Household
*
Number over 62
*
E-mail
*
Mobile Number
*
-
Area Code
Phone Number
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December Monthly Family Donation
$
50.00
December Monthly Family Donation
December IRC Reimbursement
$
50.00
IRC Reimbursement Payment for Recreational Services, Basketball, Dance, Karate, Soaring Eagles
December Monthly Family Donation
$
75.00
November Monthly Family Donation
December IRC Reimbursement
$
75.00
IRC Reimbursement Payment for Recreational Services, Basketball, Dance, Karate, Soaring Eagles
December Monthly Family Donation
$
100.00
November Monthly Family Donation
December IRC Reimbursement Payment
$
100.00
IRC Reimbursement Payment for Recreational Services, Basketball, Dance, Karate, Soaring Eagles
Already donated this month via Zelle, Cash, Check or Online Banking!
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Free
Please hit PayPal to check out. (Zelle - rocknourdisabilities@gmail.com)
Total
$
0.00
Payment Methods
Debit or Credit Card
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the form.
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