REGISTRATION FORM
Workshop Title
Date:
Location:

Name *
Name
Address *
Address
Cell Phone *
Cell Phone
Home Phone/Emergency Number *
Home Phone/Emergency Number

 

Payment information:

Thank you for registering for my workshop! To finalize this registration, payment must be made in full. The tuition is $ and can be made by check or credit card. If you pay before [INSERT DATE] the Early Bird tuition is ($). If you must change your plans unexpectedly… Once your payment is made, you will receive a Material List (via email) for this workshop.

To pay by credit card: please contact me at 973-403-9374.

To pay by check: make payment out to “Margie Samuels” and send to:

Margie Samuels
17 Boxwood Drive
West Caldwell, NJ 07006