Balinese Dance Workshop Registration Form « Back to main Balinese Dance Workshop page 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 INFORMATIONFull Name:* First Last Gender:*SelectFemaleMaleDate of Birth:*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearPlace of Birth (city/state/country):* Occupation: E-mail:*Home Address:* Street AddressCityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState / Province / RegionPostal / Zip CodeHome 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).* PAYMENTIndividual 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?*Select YesNoIf 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: *SelectIndividual Donation via PayPal/Credit/Debit CardIndividual Donation via CheckIndividual Donation via VenmoFamily Package for 2 via PayPal/Credit/Debit CardFamily Package for 2 Donation via CheckFamily Package for 3 via PayPal/Credit/Debit CardFamily Package for 3 via CheckIf you choose payment by check, please mail check to:Elvina Setia / Indonesian Community of New England, Inc.1 Jacobs St., Peabody, MA 01960If you choose payment by Venmo, please send yours to www.venmo.com/iconePayments 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.orgPlease 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! SubmitReset Share this:Click to share on Facebook (Opens in new window)Click to share on Twitter (Opens in new window)Click to share on WhatsApp (Opens in new window)Click to print (Opens in new window)