REGISTRATION FORM:

 

A DEPOSIT OF $100. TO RESERVE SEAT IN CLASS.

 

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_______________________________________________________

 

DEPOSIT OF $100. REQUIRED TO RESERVE SEAT IN CLASS.

 

CHECK ENCLOSED          MONEY ORDER ENCLOSED          AMOUNT_____________US FUNDS ONLY

 

CLASS & TEACHER:  (PLEASE MAKE 3 SELECTIONS)

 

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