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.

Schedule Your First Black Belt Mastery Class

First Name*
Last Name*
E-mail Address*
Street Address*
Zip/Postal Code*
Home Phone*
Business Phone
Which day works best for your 1st Intro Class?
Which time works best for you?
What else would you like to tell us about you/your child?

Please enter the word that you see below.