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Application Form for Youth & Adult (15yrs & up)

Class sessions: Saturdays / March 9-23, 2019 (3 class sessions)

Times: 1pm - 2.30pm

Location: Green Street Studios (studio 1), 185 Green St, Cambridge, MA 02139

STUDENT INFORMATION

Full Name:*

First

Last

Gender:*

Date of Birth:*

day

month

year

Place of Birth (city/state/country):*

Occupation:

E-mail:*

Home Address:*

Street Address City State / Province / Region Postal / Zip Code

Home Phone: *

Area Code

Phone Number

Cell Phone: *

Area Code

Phone Number

Other useful note about you, e.g. dance experience, learning style, interests, etc.:

How did you hear about this workshop? E.g.: friend, FB, ICONE's website, twitter, instagram, event listing, other (please specify).*

PAYMENT

Individual donation: $55/student for all 3 workshop sessions.

Also available, Family Package donation:
1.$99/2 family members for 3 workshop sessions.
2.$140/3 family members for 3 workshop sessions.

Will your placement in our dance workshop be part of the Family Package?*

If you choose 'Yes' on the above question, please insert names of your other family members that will participate in our classes. Max. 2 other family members to be included in the Family Package.

Family member name 1:

First

Last

Family member name 2:

First

Last

(Please separately register the other family members mentioned above once you are done with this student's registration)

Payment For: *

If you choose payment by check, please mail check to:
Elvina Setia / Indonesian Community of New England, Inc.
1 Jacobs St., Peabody, MA 01960

If you choose payment by Venmo, please send yours to www.venmo.com/icone

Payments for Family Package can be done by checks or Venmo to the address/account stated above. Checks must be received by us within 1 week of application submission.

For comments or questions, please email us at: contact@icone-inc.org

Please click the 'Submit' button below to confirm your registration.

Notes:

If you are using PayPal or Credit Card/Debit Card to make payment, after clicking the 'Submit' button below please wait for few seconds until the page to make payment appears.
If you are paying by check or Venmo, after clicking the 'Submit' button below, no further action is needed. You can send your check or Venmo payment separately to the address/account stated above.

Thank you and we hope to see you in our Bali dance workshop soon!

Application Form for Youth & Adult (15yrs & up)

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