Group Registration

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Shaded Fields Are Required
CLASS CONTROL NUMBER  (This number will be provided to you by your local class organizer.)  
*First Name:  
*Middle Name:  (If no middle name, enter "NONE")
*Last Name:  
*Generation   (Jr., II, etc....  Or, enter "NONE")
     Nickname   (If no nickname, leave blank)
*Address:  
*City:  
*State:  
*ZIP:  

*Above information must be the same as Drivers License or State ID

 
Phone:   (include area code)
Alt. phone:   (include area code)
Ext:  
Email (Your email address will be added to our free Newsletter list.  You may opt-out at any time):  
Date of birth:  
Form of identification:  

Issuing state:

 
DL or ID number:  

Participation in our CHL Class will require that you sign a Hold Harmless Agreement that will be provided to you on the day of the class.

If you wish to review the terms and conditions of the Agreement Click Here.


By submitting this form, I acknowledge that I have read and accept the terms and conditions of the Staying Alive, Inc., Cancellation and Re-scheduling policies.


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