EXO PRO-OP APPLICATION
FULL NAME:
*
First Name
Last Name
TALENT NAME: (if applicable)
ADDRESS:
*
STREET ADDRESS
Street Address Line 2
CITY
STATE/PROVINCE
ZIP CODE
DATE OF BIRTH:
*
-
Month
-
Day
Year
Date
PHONE:
*
Please enter a valid phone number.
E-MAIL:
*
example@example.com
SELECT YOUR PROGRAM:
*
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BEGINNERS
$1,500.00 One Time Payment -or- $1,000 Initial Commitment and $500.00 per month thereafter.
$
1,500.00
Payment Plan
One Time Payment
Monthly Plan
ESSENTIALS
$750 Initial Commitment and $150 per month thereafter
$
750.00
EMERGENCY CONTACT INFORMATION
EMERGENCY CONTACT:
*
First Name
Last Name
PHONE:
*
Please enter a valid phone number.
RELATIONSHIP:
*
Please Select
Spouse
Sibling
Parent
Friend
Family
SIGN HERE:
*
SUBMIT
SUBMIT
Should be Empty: