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: | Thursday-01 Jan ( - ) |
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 |