SEG 2-04-20 Class Registration

SEGMENT TWO CLASS REGISTRATION

February 24, 25, 26; Monday, Tuesday, Wednesday: 8pm-10pm
Class Dates
First Name*
Middle Name*
Last Name*
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When did you get your Level 1 License?*

MonthDayYear
High School Attended*
Where did you take Segment 1 class?*
Parent/Guardian Name*

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

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

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

Pay now with cardPay on the first day of class

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