SEG 1-06-19 Class Registration

SEGMENT ONE CLASS REGISTRATION

January 6 - January 23, 2020 Monday-Thursday 6-8pm
Class Dates
First Name *
Middle Name *
Last Name *
Birth Date *

Month Day Year Date Picker Icon

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian Name *

First Name Last Name
Phone Number *
Parent E-mail *
This e-mail will receive a confirmation receipt.
Student or Secondary E-mail
This e-mail will NOT receive a confirmation
Gender

Female Male
Comments or Extra Information
Future Info From Mr.R's

Yes, I want to receive updates via e-mail!
Payment *

Pay with card Pay on the first day of class

CHECKOUT *

SEGMENT ONE CLASS $ 320.00

Enter coupon

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty: