REGISTRATION FORM:  SEND TO:  Elva Leins, Director - 200 Westcott Court  -  Deland, FL  32724

 

NAME___________________________PHONE_______________CELL PHONE______________

 

ADDRESS____________________________________________________________________

 

EMAIL_______________CITY/STATE/PROVINCE_________________ZIP/POSTAL___________

 

CIRCLE THE EXPLANATION THAT APPLIES TO YOUR SITUATION:

PRIVATE                    DOUBLE                  DAY STUDENT                        SPOUSE        

SPECIAL DIET                                   HANDICAP                       HEALTH CONDITION

 

EXPLAIN:___________________________________________________________________

 

EMERGENCY NAME AND PHONE NUMBER___________________________________________

 

ROOMMATE PREFERENCE_______________________________________________________

 

CHECK ENCLOSED          MONEY ORDER ENCLOSED          AMOUNT_____________US FUNDS ONLY

 

CLASS & TEACHER:  (PLEASE MAKE 3 SELECTIONS)

 

1________________________2_________________________3_______________________