Momentum Education... For Life's Possibilities

Workshop Registration Basic District of Columbia
  1. Basic Enrollment Form District of Columbia

    Thank you for choosing to enroll. Enrolling online will take just a few minutes. Simply fill out this form and submit.

  2. Course Selection(*)
    Invalid Input
  3. Course Date(*)
    Invalid Input
    ** Select a course date shown from the list to the right of your screen.
  4. First Name(*)
    Please type your first name.
  5. Preferred Name
    Please type your perferred name.
  6. Last Name(*)
    Please type your last name.
  7. Occupation
    Invalid Input
  8. Invalid Input
  9. Street Address(*)
    Please type your street address.
  10. Apartment Or Suite #
    Please type your apartment or suite #.
  11. City(*)
    Please type your City.
  12. State(*)
    Please type your state.
  13. Zip Code(*)
    Please type your zip code.
  14. Home Phone(*)
    Please type your Home Phone.
  15. Work Phone
    Invalid Work Phone.
  16. Cell Phone
    Invalid Cell Phone.
  17. E-mail(*)
    Invalid email address.
  18. Birth Month(*)
    Invalid Input
    **Enter your birth Month
  19. Birth Day(*)
    Invalid Input
    **Enter your birth Day
  20. BirthYear(*)
    Invalid Input
    **Enter your birth Year
  21. I Was Referred By(*)
    Please type who referred you.
  22. Payment Type(*)
    Invalid Input
    --Please note for anyone that selects the January 26-29 Basic Workshop, that your credit card number is only to hold your seat and will only be charged a fee of $100 USD if you do not show up for the event or you do not cancel your participation at least 48 hours before the start of the Workshop.
  23. Credit Card Type(*)
    Invalid Input
  24. Credit Card #(*)
    Invalid Input
  25. Expiration Month(*)
    Invalid Input
  26. Expiration Year(*)
    Invalid Input
  27. CCID #(*)
    Invalid Input
    ** 3-4 digit number on the back or front of your card
  28. 1st Goal I Wish To Accomplish(*)
    Invalid Input
  29. 2nd Goal I Wish To Accomplish(*)
    Invalid Input
  30. 3rd Goal I Wish To Accomplish(*)
    Invalid Input
    Invalid Input
  32. Enter Security Code
    Enter Security Code
      RefreshInvalid Input
You are here: Enroll Basic District of Columbia