REGISTRATION FORM FOR CAZENOIVA, NEW YORK SEMINAR

MAIL TO:  DORIS ACKILLI, DIRECTOR - P O BOX 189 - SOUTH SALEM, NEW YORK, 10590

 

NAME__________________________________________TELEPHONE______________________________________

 

ADDRESS_______________________________________EMAIL__________________________________________

 

CITY,STATE/PROVINCE______________________ZIP/POSTAL_____________ROOMMATE_____________________

 

CIRCLE ITEM THAT APPLIES TO YOUR SITUATION:

DAY STUDENT      SMOKER        NON-SMOKER          HEALTH CONDITION                          

 

PRIVATE      DOUBLE         SHOVESUITES          FARBER        EARLY ARRIVAL         HANDICAP

 

EXPLAIN______________________________________________________________________________________

 

EMERGENCY PHONE NUMBER_______________________________________________________________________

 

TEACHER AND SUBJECT:

 

1______________________________________________4_____________________________________________

 

2______________________________________________5_____________________________________________

 

3______________________________________________6_____________________________________________