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Personal Details
Women Attending

 

     
 First Name:    State: 
 Last Name:

  Zip:
Address:    Phone Number:  
City:    Email: 
          
Payment Details: 1 Session $18 | 8 Sessions $65  | Sponsorship $180
Please charge my:   Card Number:
Exp. Date:       Total Charge  Amount:  $
Comments:    $180 Sponsorship