ROOTED REGISTRATION

Rooted begins again on January 5, if you would like to sign up, please fill out the form and we will be in touch with you.

Warning!

This form cannot be submitted until an administrator completes the setup process to receive online payments.

SESSIONS

Date/Time:

*

Please select all that apply.

Sunday @6:30 Wednesday @6:30

YOUR INFO:

Full Name

*

Email

*

This address will receive a confirmation email

Phone

*

Address

*

Birthdate

*

Age

*

Gender

*

Please select all that apply.

Male Female

Marital Status

*

Please select all that apply.

Single Married Separated Divorced Widowed

Do you have any children?

*

Please select all that apply.

Yes No

If so, what ages?

*

PAYMENT INFO- $15/book

Payment

1 ($15) 2 ($30) 3 ($45) 4 ($60)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Rooted begins again on January 5, if you would like to sign up, please fill out the form and we will be in touch with you.

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