PARTICIPANT’S NAME:___________________________________________________________________
ADDRESS:_____________________________________________________________________________
C/S/Z:________________________________________________________________________________
EMAIL:_______________________________________________________________________________
PHONE NO.:_______________________________ CELL NO.:___________________________________
IN CASE OF AN EMERGENCY CONTACT:_____________________________________________________
RELATIONSHIP:________________________________________________________________________
PHONE NO.:_______________________________ CELL NO.:___________________________________
SCHEDULE: MONDAY CERAMICS CLASS 5:30-6:30pm – Instructor, Lisa A. Busch
MONDAY CERAMICS CLASS 5:30-6:30pm – Instructor, Lisa A. Busch
CHARGES AND PAYMENTS VISA / MASTER CARD / AMEX / DISCOVER
VISA / MASTER CARD / AMEX / DISCOVER
ACCOUNT #:_________________________________AMOUNT: $________________________________
NAME ON THE ACCOUNT:________________________________________________________________
ADDRESS (IF DIFFERENT FROM ABOVE)_____________________________________________________
EXPIRATION DATE:________________________________ 3 DIGIT SECURITY CODE _________________
$85.00 for the course prepaid (or $20.00/hr at door)
$10.00 supplies (this is a one-time fee per course)
$10.00 registration (this is a one-time fee paid annually)