test page for paypal functionality for Maap Jr registration Name of Youth Attending Class* First Last Age of Youth Attending Class*10 - 1112 - 1314 - 1516 - 17Address 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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*Apr 25; May 2, 9, 23, 30; and Jun 6All 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.PhoneThis field is for validation purposes and should be left unchanged.
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