PERSONAL INFORMATION
Name
Address1
Address 2
City, State, Zip
Day Phone
Evening Phone
Cell Phone
Email

EVENT INFORMATION
Event Title
Ticket Price
# of Tickets
EVENT TOTAL

CLASS INFORMATION
Practice or Workshop Title & Dates	Fee
CLASS TOTAL

MEMBERSHIP INFORMATION

Please indicate your member status: ....... Member Not a Member

PAYMENT INFORMATION
TOTAL TO BE CHARGED

Credit Card Type	Select Credit Card Visa Mastercard
Credit Card Number
Name on Credit Card
Expiration Date (mm/yy)
Security Code on back of card