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.

Please register me for the: *

First Name *

Last Name *

Street Address *

City *

State *

Postal Code *

Home or Cell Phone *

Work Phone (P.O. contact):

Email Address *

I am a *

Other:

Years Signing: *

Sign Language Mode Used: *

Have you attended a prior SEE Skillshop? *

Yes

No

Prior Skillshop Location:

Year(s) Attended:

Prior Skillshop workbook was:

Ended at lesson number:

My instructor for that Skillshop was:

Skillshop Fees (please select one):

	-
Weeklong Early Registration ($350)	-
Weeklong Registration ($385)	-
Weekend Early Registration ($175)	-
Weekend Registration ($200)	-
Nebraska Early Registration + Meals ($200)	-
Nebraska Weekend Registration + Meals ($225)	-

Total Fees: *

Full payment for all sessions is due at the time of registration. A fee may be charged for no-shows or if you cancel less than 7 days prior to the event date.

I am paying by:

Credit Card Number:

Expiration Date (mm/yyyy):

Name on Credit Card:

Email Address & Tel# of PO Contact:

When using a Purchase Order(PO), Email a copy of the PO to seecenter@seecenter.org or FAX to the number below within 5 days of this Registration in order to confirm the registration. The PO should be made out to:

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

FAX: (562) 795-6614

seecenter@seecenter.org