Skillshop Registration Form

Thank you for your interest in attending a S.E.E. Skillshop. To reserve your seat, please fill out the information below.

* First Name

* Last Name

* Address 1

Address 2

* City

* State

* Postal Code

* Home Phone

Work Phone:

Fax

* Email Address

* I am a

Other:

* Years Signing:

* Sign Language Mode Used:

* Please register me for the:

* Location:

Please enter information below for each attendee:

* Have you attended a prior SEE Skillshop? (If no, please enter "NA" in the next five fields)

Yes

No

* Prior Skillshop Location:

* Year Attended:

* Prior Skillshop workbook was:

* Ended at lesson number:

* My instructor for that skillshop was:

Skillshop Fees (please select one):

	you must have at least one item
Weeklong Early Registration ($350)
Weeklong Late Registration ($385)
Weekend Early Registration ($175)
Weekend Late Registration ($200)
ESSE Evaluation ($300)
Scholarship Place Holder-Weekend ($75)
Scholarship Place Holder-Weeklong ($150)

* Total Fees:

Full payment for all sessions is due at the time of registration.

I am paying by:

Credit Card Number:

Expiration Date (mm/yyyy):

Name on Credit Card:

Credit Card Billing Address:

When using an Institutional Purchase Order, hard copy of the PO must accompany the registration and must be for the full amount of registration. Please print this form and either FAX or mail the completed form with the PO to:

S.E.E. Center for the Advancement of Deaf Children
PO Box 1181
Los Alamitos, CA 90720-1181

FAX: (562) 795-6614

* Indicates Response Required


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