REGISTRATION FORMRegistration for Sept. classes begins on August 1, 2007. Please print clearly. Name___________________________________ Address _________________________________ City, State, Zip____________________________ Home ( _____ )___________________________ Business ( _____ ) _________________________ Mobile ( _____ )___________________________ Email ___________________________________ Date of Birth: _____ / _____ / _____ Allergies (i.e. latex or meds):_________________ ________________________________________ In case of emergency, contact: Name__________________________________ Phone ( ______ ) ________________________ Method of payment: o Check to AD Academy o Money Order o Credit Card o Other________ o Visa o Mastercard o American Express CC Acct # ________________________________ Expiration date: ______ / ______ Please print and mail this form to: |