Enroll Group Classes

Group Classes Enrollment

• Please complete each field or enter N/A when not applicable.

STEP 1: STUDENT INFORMATION

EMAIL CONTACT :
PRIMARY PHONE :
Student Name : First
Last
DOB (Month) :

DOB (Day) :

DOB (Year) :
School :
Grade in School : (or year to enter Kindergarten)
Address :
City :
State :
Zip :
Parent 1 : First Name

Last :
Parent 2 : First Name
Last :
How did you hear about Milder?
If friend, name


2: ACTIVITY SELECTION

Course :

Day :

Time :

3: PAYMENT OPTION

AUTOPAY: Electronic Check. This information must be provide for Enrollment to be processed.

Bank Name:

ach_check
Routing Number:

Account Number: