A Chance to Dance
Fill out the form carefully and sign up each participant.
Class Date
May, Friday 3rd - 5:00 - 6:00 pm
Class Date
May, Friday 10th, 5:00 - 6:00pm
Class Date
May, Friday 17th, 5:00 - 6:00pm
Class Date
May, Friday 24th, 5:00 - 6:00pm
Class Date
May - 31st 5th week no class
Class Participant Name
*
First Name
Last Name
Gender
*
Male
Female
N/A
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
My Products
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May Monthly Family Donation
$
50.00
May Monthly Family Donation
May Monthly Family Donation
$
75.00
May Monthly Family Donation
May Monthly Family Donation
$
100.00
May Monthly Family Donation
Already donated this month via Zelle, Cash, Check or Online Banking!
$
Free
Please hit PayPal to check out. (Zelle - rocknourdisabilities@gmail.com)
Total
$
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.
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