Momentum Education... For Life's Possibilities

Workshop Registration Teen Basic DC
  1. Teen Basic Enrollment Form DC

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

  2. Course Selection(*)
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    **(includes a $50 non-refundable administration fee)
  3. Course Date(*)
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    ** Select a course date shown from the list to the right of your screen.
  4. Name(*)
    Please type your first name.
  5. Parent's/Guardian's Name
    Please type your perferred name.
  6. Street Address(*)
    Please type your street address.
  7. Apartment Or Suite #
    Please type your apartment or suite #.
  8. City(*)
    Please type your City.
  9. State(*)
    Please type your state.
  10. Zip Code(*)
    Please type your zip code.
  11. Home Phone(*)
    Please type your Home Phone.
  12. Cell Phone
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  13. E-mail(*)
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  14. Parent's/Guardian's Email(*)
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  15. I Was Referred By(*)
    Please type who referred you.
  16. Payment Type(*)
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  17. Credit Card Type(*)
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  18. Credit Card #(*)
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  19. Expiration Month(*)
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  20. Expiration Year(*)
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  21. CCID #(*)
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    ** 3-4 digit number on the back or front of your card
  22. 1st Goal I Wish To Accomplish(*)
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  23. 2nd Goal I Wish To Accomplish(*)
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  24. 3rd Goal I Wish To Accomplish(*)
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  25. Comments
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  26. Your Email(*)
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  27. Enter Security Code
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  28.   
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