Zoho Creator - Registration Form

Registration Form

Personal Data

Class/Session *
18a Tots: Sat. 07/18- 08/29, 10 am (7wks)--120 South Estes Dr Chapel Hill 27514--$107.50
18b Babies: Sat. 07/18- 08/29, 11 am (7wks)--120 South Estes Dr Chapel Hill 27514--$107.50
19a Tots: Sat. 07/25- 08/29, 10 am (6wks)--3400-A8 Westgate Dr Durham 27707--$95
19b Babies: Sat. 07/25- 08/29, 11 am (6wks)--3400-A8 Westgate Dr Durham 27707--$80
20 Tots: Thu. 09/03- 10/22, 9:30 am (8wks)--3236 Shannon Rd Durham 27707--$120
21 Babies: Thu. 09/03- 10/22, 10:30 am (8wks)--3236 Shannon Rd Durham 27707--$105
22 Tots: Sat. 09/12- 10/31, 9:30 am (8wks)--3400-A8 Westgate Dr Durham 27707--$120
23 Babies: Sat. 09/12- 10/31, 10:30 am (8wks)--3400-A8 Westgate Dr Durham 27707--$105
24 Tots: Thu. 09/10- 10/29, 9:30 am (8wks)--10810 Globe Rd Raleigh 27560--$120
25 Babies: Sat. 09/10- 10/29, 10:30 am (8wks)--10810 Globe Rd Raleigh 27560--$105

Name *

Child 1 Name *

Child 1 Date of Birth * [MM/dd/yyyy]

Child 2 Name

Child 2 Date of Birth [MM/dd/yyyy]

Phone
(9991234567) *

Mobile Phone
(9991234567)

Email Address *

Street Address *

City *

State *

Zip Code *

Comments

Referral

How did you hear about
Salsa Babies/Salsa Tots? *

Emergency Contact

Name *

Relationship *

Phone
(9991234567) *

Medical Information

Doctor's Name *

Doctor's Phone
(9991234567) *

Health/Allergies?

Waiver
Please read the waiver link and check the box below to agree to the terms and conditions of the waiver.

I have read, understood and agree to the terms and conditions stated in the waiver above *

Tuition Please make your check payable to Susana Ramsey and mail to:
Susana Ramsey, 6025 Garrett Road Durham NC 27707

Tuition *
$80.00 (6wk Babies/New Student)
$95.00 (6wk Tots/New Student)
$107.50 (7wk Tots/New Student)
$105.00 (8wk Babies/New Student)
$110.00 (8wk Babies/twins)
$120.00 (8wk Tots/1 child)
$125.00 (8wk Tots/twins)
$205.00 (8wk Tots/2 siblings over 12 m)
$290.00 (8wk Tots/3 siblings over 12 m)
$80.00 (8wk Babies/Returning Student)
$100.00 (8wk Tots/Returning Student)
FTC

Promo Code

Bank Name *

Check # *

Verification
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Verification Code

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