To register, please complete the form below.

Refund policy: Registrations that are cancelled less than 7 days prior to the class start date are subject to a cancellation fee of $25. Cancellations more than 7 days prior to the class start date, will be refunded in full less a $10 fee for credit card refund processing.

Session:

Blaine Safeway Classroom
In Person

Start Date:

Mon, Oct 21, 2024

End Date:

Thursday, November 14, 2024

Times:

6:00 PM - 9:00 PM

Days of the Week:

Mon, Tue, Thu

Package Cost:

$460.00

Paid in Full Amount:

$450.00

Paid in Full Discount:

$10.00

1^st Classroom Payment:

$140.00

2^nd Classroom Payment:

$140.00

1^st BTW Payment:

$90.00

2^nd BTW Payment:

$90.00

Student Information

* Indicates Required Field

Student First Name: *

(As it appears on student's birth certificate)

Student Middle Name: *

(As it appears on student's birth certificate. If no middle name, please type leave this field blank)

Student Last Name: *

(As it appears on student's birth certificate)

Nickname:

(optional)

Suffix:

(optional, Example "Jr." or "III" as it appears on birth certificate)

Primary Address Information

Address 1 *

Address 2

City *

State *

Zip *

Secondary Address Information

Address 1

Address 2

City

State

Zip

Home Phone:

(optional)

Student Cell Phone:

(recommended)

Student Email:

(recommended)

Birthdate: *

(mm/dd/yyyy)
Safeway's program is for teens under age 18

Gender:

(optional)

Parent/Guardian Information

Parent/Guardian (required)

First Name: *

Last Name: *

Email: *

Phone: *

Additional Parent/Guardian (optional)

First Name:

Last Name:

Email:

Phone:

Note to Instructor (optional):
(Please note any special circumstances
concerning the student)

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