Jim's MAIL-IN REGISTRATION FORM

MAIL-IN or FAX REGISTRATION FORM

IT'S EASY:

(1) SELECT your dance class.

(2) PRINT THIS PAGE, fill out & detach your Registration Form below.

(3) FAX REGISTRATION - Fax your Registration Form to the correct Sponsoring Organization with your MC/Visa/Discover card # and your expiration Date !

or (3) MAIL REGISTRATION - Mail your Registration Form to the correct Sponsoring Organization with your check payable to that Organization !

FOR JIM'S CLASSES in:

WATERBURY CT, mail to Waterbury Adult Education, 28 E. Clay St., Waterbury, CT 06706 (Tel. 203.574.8038)

WATERTOWN CT, mail to Watertown Recreation Department, 51 Depot St. Suite 108, Watertown, CT 06795 (Tel. 860.945.5246)

WEST HARTFORD CT, mail / fax to LifeLearn, West Hartford Continuing Education, 28 South Main St., West Hartford, CT 06107-2447 (Tel. 860.523.3535 or 3536, Fax 860.523.3543)

WOLCOTT CT, mail to Wolcott Adult Education, Wolcott High School, 457 Bond Line Rd., Wolcott, CT 06716 (Tel. 203.879.8423)

WOODBURY CT, mail to a sponsoring organization to be determined (Jim's Tel. 860.274.2657)

THANK YOU FOR JOINING OUR CLASSES or as Elvis would say, "Thang-ya,Thang-yaverymuch !"

RETURN to "CT Classes" or "MAIN PAGE"

MAIL-IN or FAX REGISTRATION FORM for Jim's Classes

I, the undersigned, by applying to participate in the following class in the Sponsoring Organization's program, do hereby waive, release, absolve, indemnify, and agree to hold harmless the Sponsoring Organization's organizers, employees, and supervisors and Jim Zaccaria.

Agree by signing here:__________________________ Jim's Swing Dance Class titled:_______________________

MY NAME:_________________________CLASS DATES & TIMES___________________

MAIL ADDRESS:___________________________________________________________