Dance Fitness Line Dance Class 
Instructions:  Please complete this form to begin your registration for the Dance Fitness Line Dance class. You must also contact BRTC Corporate & Community Education to complete your registration and submit payment at 870-248-4180. (Registration is not complete until payment of $55 is received in full.) 
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Email *
First Name, Middle Initial, Last Name (Ex: Jane A. Doe) *
Mailing Address 
(Example: 1234 Test Way, Pocahontas, AR 72455)
 *
Date of Birth *
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Sex:
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Phone Number (Ex: (555-555-5555) *
Email Address *
If job related: Employer Name & Employer Address
How did you hear about this class?
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