Kalasala Enrollment

Payment Processing

* denotes required fields

Applicant Information

*Name:

*Date of Birth:

(mm/dd/yyyy)

*Name of Parent/Guardian:

*Mailing Address:

*Phone:

*Email:

Teacher's Information

Name of School:

Location of School:

City: State:

Teacher's Name:

Teacher's Phone:

Teacher's Email:

Date enrolled:

Program:

Pick a level:
(*required!)

Level 1
Level 2
Level 3
Level 4

Payment Information:

*Type of Card:

Amount: $ 350

*Name on Card:

*Credit Card Number:

*Exp: (mm)/ (yyyy) *CVC:

*Card Billing Address:

*City:

*State/Province: *Zip: *Country: