Virtual child enrollmentOne child per registration. Student Full Name * First Name Last Name Fall 2022 Virtual workshops dates * Monday |4 weeks| $175 | 4:00pm-5:00pm | 11/28, 12/5, 12/12 12/19 Tuesday SOLD OUT Wednesday SOLD OUT Thursday SOLD OUT Friday SOLD OUT Parents Name * First Name Last Name Parent Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone contact 1 * (###) ### #### Student Information Child's age * 5 6 7 8 9 10 11 12 Birthdate * MM DD YYYY Disabilities * Special Needs * PAYMENT INFORMATION Cardholder's First & Last Name * First Name Last Name Card Type* VISA MASTERCARD DISCOVER AMERICAN EXPRESS Credit Card # Expiration Month Expirtation Year 3 Digit code for VISA, MASTERCARD & DISCOVER | 4 Digit code for AMEX * What is the zip code that this card belongs to? * PROMO CODE Thank you! You’re child is enrolled! Woohoo! Mark your calendar. We will be in touch shortly with further class details.