Zoho Creator- Registration Form

Registration Form

Personal Data

Class/Session *
Tots II: Tue. 01/05 - 02/23, 09:30 am (8wks) -- 3400 - A8 Westgate Dr Durham 27707 --$120
Babies: Tue. 01/05 - 02/23, 10:30 am (8wks) -- 3400 - A8 Westgate Dr Durham 27707 --$100
Kids: Wed. 01/06 - 02/24, 4:30 pm (8wks) -- 3400 - A8 Westgate Dr Durham 27707 --$115
Tots: Fri. 01/15 - 03/05, 9:30 am (8wks)-- Stage Door Dance: 2720 Godley Ln #101 Raleigh 27617 --$120
Babies: Fri. 01/15 - 03/05, 9:30 am (8wks)-- Stage Door Dance: 2720 Godley Ln #101 Raleigh 27617 --$100
Tots II: Sat. 01/16 - 03/06, 10:15 am (8wks) -- 3400 - A8 Westgate Dr Durham 27707 --$120
Babies: Sat. 01/16 - 03/06, 11:15 am (8wks) -- 3400 - A8 Westgate Dr Durham 27707 --$100

Parent/Guardian Name *

Child 1 Name *

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

Child 2 Name

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

Child 3 Name

Child 3 DOB [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 * $100.00 (8wks Babies/child)
$100.00 (8wks Babies/twins)
$120.00 (8wk Tots/child)
$125.00 (8wk Tots/twins)
$205.00 (8wk Tots/2 siblings over 12m)
$115.00 (8wk Kids/child)
$200.00 (8wk Kids/2 siblings)
$85.00 (8wks each additional sibling for Babies, Tots or Kids)
FTC

Promo Code

Bank Name *

Check # *

Verification
(if you can't see the verification code, please press the refresh button on your browser)

Verification Code

(enter the characters you see in the above picture)

View Error Details

Powered by