Home Video Course Order Form

Please complete the form below to purchase the Home Video Course. NOTE: The email address used for the Student taking the course must be a Gmail address (___@gmail.com).

"*" indicates required fields

Please select from the following:*

I am signing up a student under the age of 21 of whom I am the legal parent or guardian.

I am signing myself up for the course and I am at least 21 years of age.

Student's Information

Student's Legal Name*

First Last

Date of Birth*

Student's Billing Address*

Street Address Address Line 2 City State ZIP Code

Student's Address*

Street Address Address Line 2 City State ZIP Code

Student's Cell Phone*

Student's Email*

Email MUST be a Gmail address (____@gmail.com)

Emergency Contact Name*

Emergency Contact Phone*

Parent's Information

Parent's Name*

First Last

Parent's Email*

Parent's Phone*

Different Billing Address?

Same as student's address above

Parent's Billing Address*

Street Address Address Line 2 City State ZIP Code

Payment Information

Home Video Course*

Price:

Transaction Fee*

Price: $0.00

Total

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Phone

This field is for validation purposes and should be left unchanged.