| Are you signing up an: | In Person Class |
| How did you hear about us?: | Friend |
| Billing Information: | New Student |
| Contact Information: | Guardian |
| First Name: | Jignesh |
| Last Name: | Variya |
| Email: | haresh.ambaliya2@gmail.com |
| Cell Phone: | (111) 111-1111 |
| Home Phone: | (222) 222-2222 |
| Emergency Name: | (444) 444-4444 |
| Emergency Phone: | (132) 131-2432 |
| Address: | Katargam |
| City: | Surat |
| State: | California |
| Zipcode: | 395004 |
| Student - 1st Child: | |
| First Name: | Hitesh |
| Last Name: | Ambaliya |
| Allergies?: | No |
| Describe: | Ent |
| Birthday: | 01/01/1990 |
| Location: | -- |
| Class: | Toddler Class -Lowey Hija 2 (3 - 4yrs.) |
| Class Day: | Wednesday-19 Jun (2:15 - 3:00 PM) |
| Child 1 (Group): | $520.00 |
| Student - 2nd Child: | |
| First Name: | bharat |
| Last Name: | virani |
| Allergies?: | No |
| Describe: | test describe1 |
| Birthday: | 01/01/1995 |
| Location: | Sherman Oaks |
| Class: | Lowey Hija 2 |
| Class Day: | Friday-28 Jan (1:00 - 1:30 PM) |
| Child 2 (Group): | $440.00 |
| Sub Total: | $960.00 |
| Discount: | $96.00 |
| Total Amount: | $864.00 |
| Payment Information: | |
| Name as it Appears on Card: | Haresh Ambaliya |
| Type of Credit Card: | Visa |
