Student Name *

First Name

Last Name

Contact Name

(If different from student)

First Name

Last Name

Phone *

(###)

###

####

Heartland Student *

Yes

No

Heartland Students *

you acknowledge that a certificate of approval from your teacher is required before the first class starts.

Yes

I am not involved with Heartland

Photography & Video Use *

Will you allow the use of photography and video of the student to be used in social media and other print and digital marketing use?

Yes

No

Class Options *

Please make sure to read the details for each class under the "Classes" page before selecting your class option.

Single Class

Session Class A

Session Class B