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

EVENT INFORMATION **Required 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 **Required Information
**TOTAL TO BE CHARGED

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