2. Name*
4. Street Address*
6. City*
7. State*
8. Zip Code*
10. Phone Number*
11. Email Address*
13. Date of Birth*
    Date of Birth
14. School or Employer*
18. Parent/Guardian Name (If under 18)
19. Parent/Guardian Phone Number (If under 18)
23. Type & Weekend of Course*

    All courses include in-person & blended learning. In person training will be at Querbes Rec Center 8am-7pm each day.

    1. Re-Certification ($175) Course #1: May 10
    2. New Certification ($315) Course #1: May 10 & 11
    3. Re-Certification ($175) Course #2: May 17
    4. New Certification ($315) Course #2: May 17 & 18
    5. Re-Certification ($175) Course #3: May 24
    6. New Certification ($315) Course #3: May 24 & 25
27. Amount of Payment*

    1. $175 Re-Cert
    2. $315 New Cert
    3. Half Down Payment Plan (Finance the Rest) *Must work at Rock Solid for this Option
28. Payment Method*

    1. Check (bring payment first day)
    2. Cash (bring payment first day)
    3. Credit Card (enter details below)
    4. Apple Pay (318-470-8904)
    5. Cash App ($SHELLMCMILLIAN10)
    6. Paypal (SHELLEYMC10@AOL.COM)
32. Credit Card Number
33. Expiration Date
34. Security Code

38. *ANY MAKEUPS MUST BE APPROVED AND SCHEDULED WITH SHANNON VINNING AT 318-415-9190.

    IF YOU FAIL THE COURSE, A $100 REGISTRATION FEE WILL NOT BE REFUNDED!

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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

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