MAIL OR FAX OPTION REGISTRATION FORM

IMPACT INSERVICE TRAINING 
REGISTRATION FORM

NAME: ______________________________________________

CONTACT #: ______________________________________

NAME OF SCHOOL OR PROGRAM: ________________________________________

ADDRESS:  _____________________________________

                  

                     _____________________________________

EMAIL ADDRESS: ___________________________@____________________

NAME OF WORKSHOP YOU WANT TO REGISTER FOR:                    DATE: 

__________________________________                   _________________

__________________________________                  _________________

__________________________________                  _________________

MAIL PAYMENT TO:                    MRS. CHRIS PLAY AND LEARN 

                                                             ATTN: IMPACT INSERVICE

                                                          4609 WILKINSON BLVD. 

                                                          CHARLOTTE, NC 28208

OR PLEASE PROVIDE PAYMENT INFORMATION BELOW:

CARD CARD NUMBER: ________________________             EXP. DATE: _______

BILLING ADDRESS: ___________________________            CRC CODE: _______

                                     ___________________________

AMOUNT TO CHARGE CARD:________________

SIGNATURE: _________________________________   DATE:  _____________

PLEASE MAIL THIS FORM TO THE ADDRESS ABOVE OR FAX TO (704)398-1617