Catron Community Learning Center

Teacher/Community Workshop Registration Form

Name:______________________________________________________________________

Address____________________________________________ Zip Code___________

Hm phone__________________________ Cell phone__________________________

Occupation__________________________ Wk phone__________________________

E-mail______________________________

WORKSHOP INFORMATION:

Title of Workshop/s _____________________________________________________

Dates/Times of Workshop/s______________________________________________

Price_________________________________________________________________

Form of Payment: Cash Check MasterCard Visa

Credit Card Number_____________________________________________________

Expiration Date_____________________________ Security Code________________

Billing Address________________________________________________________________

Signature__________________________________________ Date_______________

Please note that space will not be reserved until account is paid in full.
Please do not send cash in the mail.
Call 983-8102 to register by phone.

EMERGENCY INFORMATION:

Do you have any medical conditions we should be aware of?

______________________________________________________________________

List two people who can be contacted in case of emergency:

Name__________________ Phone__________

Name__________________ Phone__________

How did you hear about Catron Community Learning Center?

___School
___The New Mexican
___Kids Summer
___New Mexico Kids
___Tumbleweeds
___Yellow Pages
___Friend or Relative
___Internet Search
___Church
___Other
_________________