• Name:
  __________________________________________
• Age:
  __________________________________________
• Date of Birth:
  __________________________________________
• Parent/Guardian (if under 18):
  __________________________________________
• How did you hear about Break-Through Talent?:
  __________________________________________
• Street Address:
  __________________________________________
• City/State/ZIP:
  __________________________________________
• Telephone Number:
  __________________________________________
• Cell Phone:
  __________________________________________
• Email Address:
  __________________________________________
• Title of Class You are Registering for:
  __________________________________________
• Date of Class:
  __________________________________________
• Time of Class:
  __________________________________________
• Location of Class:
  __________________________________________
• Cost of Class:
  __________________________________________

Mail The Registration Form To:

BreakThrough Talent
48 West Center Street
Beacon, NY 12508
For Questions Call: (845) 704-1707, ext. 101

Make Checks Payable to BreakThrough Talent