A Chance to Dance
Fill out the form carefully and sign up each participant.
Class Date
June 5th - Friday - from 5:00-6:00pm
Class Date
June 12th - Friday - from 5:00-6:00pm
Class Date
June 19th - Friday - from 5:00-6:00pm
Class Date
June 26th - Friday - from 5:00-6:00pm
Class Participant Name
*
First Name
Last Name
Gender
*
Male
Female
N/A
Age
*
Ethnicity
*
Hispanic/Latino
African American
Asian
White Caucasian
Other
Number over age 62
*
City where you live
*
Family/Parent/Guardian Name
*
First Name
Last Name
Mobile Number
*
-
Area Code
Phone Number
E-mail
*
Number in Household
*
My Products
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June Monthly Family Donation
$100.00
$
100.00
June Monthly Family Donation
June IRC Reimbursement Payment
$100.00
$
100.00
IRC Reimbursement Payment for Recreational Services, Basketball, Dance, Karate, Soaring Eagles
Already Donated / Self Determination
Free
$
Free
Please hit PayPal to check out. (Zelle - rocknourdisabilities@gmail.com)
Total
$0.00
$
0.00
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit Signin
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