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
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
*
prev
next
( X )
SEGMENT ONE CLASS
$
320.00
Enter coupon
Apply
Subtotal
$
0.00
Tax
$
0.00
Total
$
0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: