Print out this form to mail or fax your registration -- One form per person

Darien Continuing Education Registration Form
 
Last_______________________________ First__________________________ Date___ /___ /___
 
Street_____________________________ City___________________________ ST____ ZIP_______
 
Home
Phone_____________________________		 Business
Phone_____________________
 
E-Mail
Address___________________________		 FAX
Phone_____________________
 
Cate. No. Course Title Start Date Day Time Fee
 

 

          
 

 

          
 

 

          

Make checks payable to "Darien Public Schools".......TOTAL=
 

 
 
__Check/Money Order:__________________
 
CREDIT CARD REGISTRATION BY FAX OR MAIL:
 
[  ] VISA#:___________________________
 
[  ] MasterCard#:______________________
 
Expiration Date: __________ / __________
 
Signature: ___________________________
Mail Registration to:

Darien Continuing Education
Box 1167
Darien, CT 06820-1167

Fax: 656-7457