NAME #1  _______________________  Social Security#  ___ - ___ - _____

NAME #2  _______________________  Social Security#  ___ - ___ - _____

Street Address   ______________________________________________

City  _______________________________  Postal Code ______________

Day Phone  __________________  Evening Phone  ___________________


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Payment Method - (please select one)

  Check            Money Order              MasterCard              VISA

Card #  ___________________________   Expiration Date  ____________

Cardholder Signature  __________________________________________


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     Course #                          Course Title                                       Fee

__________   ___________________________________   $ __________
 
__________   ___________________________________   $ __________
 
__________   ___________________________________   $ __________

__________   ___________________________________   $ __________

                                                                             Total Fees:        $ __________ 
  
(Enclose a self-addressed stamped envelope with your registration if you would like a confirmation of your enrollment.)



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  Please send me information regarding new learning programs.

Email Address:  _______________________________________________


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Guardian/Parent (required for students under 18 years of age)

Signature  ___________________________________________________

Printed Name  ________________________________________________