Pins & Needles Lesson/Class

Registration Form 2012

Last Name____________________First Name_______________________
Street Address_________________________________Apt.#_____________
City______________ State_____ Zip Code__________________
Home Phone ____---______---_______ Cell Phone______---______---_______
Email Address__________________________
Emergency Contact (for kid lessons/courses)
Name
__________________________________Phone Number ______---______---_______
Lesson Description

Class Fee

________________________________________ $__________
Course Title

Class Fee

________________________________________ $__________

Charge class fee and any materials used to:

Mastercard / Visa / American Express

Total$__________

Card Number
___ ___ ___ ___--___ ___ ___ ___ --___ ___ ___ ___--___ ___ ___ ___
Expiration Date
____ ____ / ____ ____ CVC Code:_________ Billing Zip Code:______________
________________________________________________________
Cardholders Signature or Name as it appears on the card
** Please be sure to read over our Registration Policies before signing up for any classes.
** Email completed forms to info@pinsandneedlesnyc.com. They can also be submitted via fax 212-535-6224 or dropped
off at our store. We can also register via the phone.