Address _________________________________

City, State, Zip____________________________

Home ( _____ )___________________________

Business ( _____ ) _________________________

Mobile ( _____ )___________________________

Email ___________________________________

Date of Birth: _____ / _____ / _____

Allergies (i.e. latex or meds):_________________

________________________________________

In case of emergency, contact:

  Name__________________________________

  Phone ( ______ )  ________________________

Method of payment:  o Check to AD Academy 

o Money Order  o Credit Card  o Other________

 o Visa    o Mastercard    o American Express

CC Acct # ________________________________

               Expiration date: ______ / ______