|
Please print:
Name: _________________________________________________________
Street address: _________________________________________________
City: __________________________ State: _________ Zip: _______________
Daytime phone: __________________________
Email: __________________________
| One Registrant Per Form Please |
| Class Name | Begin Date | Begin Time | Amount Fee |
| 1) | ________________________________________ | ___________ | __________ | ___________ |
| 2) | ________________________________________ | ___________ | __________ | ___________ |
| 3) | ________________________________________ | ___________ | __________ | ___________ |
Pre-payment is required for these classes.
Total amount enclosed: $________________
The registration deadline for all classes is two working days prior to the beginning of the class.
Print this page, complete the entire form and return with registration fee(s) to:
Center for Living Registration
Prairie Heart Institute - St. John's Hospital
619 East Mason Street
Springfield, IL 62701
|
