SEG 2-1-20 Class Registration

SEGMENT TWO CLASS REGISTRATION

January 13, 14, 15; Monday, Tuesday, Wednesday: 4pm-6pm
Class Dates
First Name *
Middle Name *
Last Name *
Birth Date *

Month Day Year Date Picker Icon
When did you get your Level 1 License? *

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/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

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

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

Pay now with card Pay on the first day of class

CHECKOUT *

SEGMENT TWO CLASS $ 50.00

Enter coupon

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

Should be Empty: