| Application Date:
|
_____________________ |
| Name:
|
_______________________________________________________________
(First, Last) |
| Street Address:
|
_______________________________________________________________
|
| City, State, Zip
|
_______________________________________________________________
|
| Home Phone
|
_______________________________________________________________
|
| E-Mail
|
_______________________________________________________________
|
| Emergency Phone
|
_______________________________________________________________
|
| Emergency Contact
|
_______________________________________________________________
|
| Reason for taking this class:
|
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
|
| Any medical background: [ ] Yes
[ ] No
|
| If yes, please describe:
|
_______________________________________________________________
_______________________________________________________________
|
| How did you hear about us?
|
_______________________________________________________________
_______________________________________________________________
|
| How would you like your name printed on your Certificate of Completion?
|
_______________________________________________________________
Please Print
|
| Anything else you'd like us to know? |
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
|
Please mail this form and your $100 deposit check to:
