Registration

Salsa Basics Shoes: non grip shoes recommended Apparel: casual or classy For any questions contact DMA at (478) 456-4940

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Home Phone:	Cell #: Work #:
	Email:	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *

Students entered below will be added to your family's account

Additional Information:

Other Questions/Comments:

Credit Card Verification:

Card Number: *

Name as it appears on card: *

Nickname:

Card Expiration Month: *

Exp Year: *

Address Line 1:

Address Line 2:

City:

State: Zip:*