test page for paypal functionality for Maap Jr registration

Name of Youth Attending Class*
First Last
Age of Youth Attending Class*
Address of Youth*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Name of Parent or Guardian*
First Last
Address of Parent/Guardian*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian Email*
Enter Email Confirm Email
E-news sign up
- Yes! I want to receive DRC e-news!
By checking the box above, I agree to subscribe to DRC e-news which will be sent to my email address above. I understand that I may choose to unsubscribe at any time. DRC does not exchange, rent or sell its mailing list to any outside organization.
Daytime phone*
Evening phone/cell*
Referral source*
- Court referred
- Probation referred
- Self-referred
- Other - specify below
Details for referral source "other"
Court Date
MM slash DD slash YYYY
Interview Date
MM slash DD slash YYYY
Program completion to be reported to:
M.A.A.P. Jr. Program Fee*
- Full Program Fee $75
- Deposit Only $25 - non-refundable
- Balance Due Only $50
Full program fee is $75 including deposit. Deposit of $25 is non-refundable. If paying only deposit, the balance $50 of program fee is due two weeks prior to class.
Total
$0.00
MAAP Jr Class Schedule*
All classes are held from 6:00 pm to 7:00 pm. Program consists of 6 classes.
(A) I understand that registration will be complete when: (1) payment is made in full; (2) DRC sends a confirmation email with subject line "anger management" to the email supplied above; (3) I reply to the DRC email and agree to the time/location; and (4) I receive a final registration/payment confirmation email from DRC. (B) The deposit of $25 is non-refundable. 48 hours advance notice is required if unable to attend. A rescheduling fee of $5 will apply. (C) There is a $15 refund fee for refund of balance payment of $50. No refunds after 60 days. (D) No reminders will be sent. I will be responsible for my child keeping the class commitment.*
- I have read, understand and agree to the above terms by typing my name in the signature box.
Signature of Parent/Guardian (required)*

TYPE NAME IN SIGNATURE BOX AND CHECK "I AGREE" BOX ABOVE.
Email
This field is for validation purposes and should be left unchanged.