Chakra Introductory Class Enrollment Form

Class:

Name:

Address:

City: State: Zip Code:

Home Phone: Best time to reach me:

Work Phone: Best time to reach me:

Cell Phone: Best time to reach me:

Email: @
(please enter separately - this helps stop spammers)

Please select preferred class date:

Tuition for class is $30 due at start of class. Pay one week prior to the date of your class and receive a $10 discount.