GENERAL INFORMATION

First Name (parent/adult)

Last Name (parent/adult)

Phone (parent/adult) *

Email (parent/adult) *

Gender

Date of birth

Referral Source

Address

Street Address

City

State

Country

Postal Code

Appointment & Student Information

Preferred Day(s) & Time(s)

Student Name (*if different)

Student Email (*if different)

Student Phone (*if different)

Paid By

Sell Products *

1 week - 30 min lesson (*prorated)

$45

2 weeks - 30 min lesson (*prorated)

$90

3 weeks - 30 min lesson (*prorated)

$135

4 weeks - 30 min lesson (*first month)

$180

1 week - 60 minute (*prorated)

$90

2 weeks - 60 minute (*prorated)

$180

3 weeks - 60 minute (*prorated)

$270

4 weeks - 60 min lesson (*first month)

$360

Registration Fee

$50