Madison Six-Week Class Registration Form *If you would like to redeem one or more drop in credits, you must select the appropriate number of drop in credits from the "Payment Amount" drop-down. **If you apply more drop in credits than you have in your account, your card will automatically be charged the difference. Contact Miss Pole to inquire about your drop in credit balance.  Student Information     First Name: * Last Name: * Zip Code: * Phone: * Email: * Class Information    Class Name: * Studio Location: Select Studio Location Brookfield Kenosha Madison Class Start Date: * Class Start Time: * Payment Information Payment Amount: * $85: Full Class Payment $70.80: Apply 1 Drop In Credit $56.64: Apply 2 Drop In Credits $42.49: Apply 3 Drop In Credits $28.33: Apply 4 Drop In Credits $14.16: Apply 5 Drop In Credits $0: Apply Six-Week Class Credit $150: 2Four$150 Promo $15: Drop In $10: Open Pole $0: Donation Workshop - Exclude Payment Info Credit Card Number: (16 digits) Expiration Date: CVV:  Promo Code: E-signature I, , certify that I have read the Miss Pole Release Agreement, understand it, and I agree to be bound by its terms and conditions. Comments: Enter comments here!