After-School Activities Listing Form

Business Name:

Contact Name:

Billing Address:

City, State, Zip:

Phone:

Email Address:

Please select months to be published:

Select the number of times you would like your advertisement to run. Please note that frequency discounts are available. 1-5 months: $70 per month. 6-11 months: $65 per month. 12 months: $60 per month.

Payment Information:

Please tell us which option you will be using for payment. Your card will be charged on or around the 15th of the month prior to publication.

Credit Cart Number (if applicable):

Expiration:

Security Code:

Check Number (if applicable):

Receipt Required:

If you need a receipt, please list the email address of the individual who should receive the receipt.

Listing Info

Activity/Program Name:

Address (if different from above):

City, State, Zip (if different from above):

Contact Name - Admissions:

Phone Number - Admissions

Email Address - Admissions:

Website Address:

Ages/Grades

50 Word Description:

This is a description of your school/programs.

Sales Representative:

If you know the name of your sales rep, please choose their name.