Appointment Contact Form

Please use this form to schedule your first Introductory Class and claim your 30-Day Free Trial Program as a part of our Special Internet Offer.

Simply complete the form and use the button at the bottom to submit.

PLEASE NOTE: This form is for those living in the local areas of Selinsgrove, Danville, Lewisburg, Sunbury, and others around the WCI Main Academy. NOT for long-distance students. If you are not from the local area and wish to send something to the academy or to Shidoshi Miller directly, please use this form instead.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Schedule Your First Black Belt Mastery Class
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-Mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Home Phone*
Business Phone
Which day works best for your 1st Intro Class?	---Select---Monday Tuesday Wednesday Thursday Friday Saturday (Morning only)
Which time works best for you?	---Select---9am 10am 11am Noon 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm
What else would you like to tell us about you/your child?
Please enter the word that you see below.