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2012 - 2013 Season Registration

Student First Name:

Boy

Girl

Please select Gender:

Last Name:

Fall Grade

2012:

School Attending:

Telephone with Area Code:

Format: 858 555-1212

Email Address:

Mailing Address (street):

City:

State:

Zip Code:

Select Class Choice:

Click here to review Class Choices if needed (opens in a new window):

Cotillion Class Location Choices:

Select Payment Option Below:

Full Payment (for any Class or event)

Cotillion Down Payment $125.00

All Participants of the Cotillion must be Paid for In Full with confirmation from the Gollatz office before attendance. Financial Transactions are not conducted at Cotillion Events.

No Refunds after 30 days of deposit. A declined Credit Card will be subject to a $10.00 service fee. A Check returned for non-sufficent funds will be subject to a $25.00 service fee

If you would like to be a chaperone for the Cotillion, Please contact the office with the date you wish to volunteer. You may submit a date below or contact the office directly at (800) 832-4574

Credit Card Number :

Expiration Date :

Credit Card Format: 5555-4444-5555-4444

Format: 09/12

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You may choose to fax your Registration to 909 880-8114

Required Field *

I would like to Volunteer as a chaperone for an event

Upon Submission you will receive a confirmation by mail.

Yes

NO

Date: