Henna Nights
Registration & Payment Form
Fridays
5 PM - 7 PM
Kaleidoscope Discovery Center
609 N. Rolla St. Rolla, MO 65401
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Selection (choose which days you are registering for. Be sure to not select single days AND the entire month so you're not over billed).
*
Friday, June 26 (free)
Entire month of July (3, 10, 17, 24, 31) $35
July 3 ($10)
July 10 ($10)
July 17 ($10)
July 24 ($10)
July 32 ($10)
Entire month of August (7, 14, 21, 28) $35
August 7 ($10)
August 14 ($10)
August 21 ($10)
August 28 ($10)
Entire month of September (4, 11, 18, 25) $35
September 4 ($10)
September 11 ($10)
September 18 ($10)
September 25 ($10)
Entire month of October (2, 9, 16, 23, 30) $35
October 2 ($10)
October 9 ($10)
October 16 ($10)
October 23 ($10)
October 30 ($10)
Entire month of November (6, 13, 20, 27) $35
November 6 ($10)
November 13 ($10)
November 20 ($10)
November 27 ($10)
Entire month of December (4, 11, 18, 25) $35
December 4 ($10)
December 11 ($10)
December 18 ($10)
December 25 ($10)
How are you paying?
*
Pay ONLINE with this form (PayPal or Credit Card) *PREFERRED OPTION BY KDC*
Check or Cash
Total Owed (read-only field)
I agree that the amount calculated above is correct and will pay it to The Kaleidoscope Discovery Center
*
Yes, I agree
No, I believe it's incorrect. I'll explain below how much I think I owe.
If you believe the amount the form calculated is wrong, please explain and share how much you think you owe below.
*
Pay on PayPal or with Credit Card (no PayPal account required)
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