|
|
Download a Class Registration Form (pdf)
American
Red Cross -- Polk County Chapter
Course
Registration Form:
Course
Title:_____________________________________________________________________________
Course
Title:_____________________________________________________________________________
Course
Title:_____________________________________________________________________________
Total
Cost: $_____________
______________________________________________________________________________
Last
Name
First Name
M.I.
______________________________________________________________________________
Home
Address
________________________________________________________________________________
City
State
ZIP
_________________________________________________________________________
Day Phone
Evening Phone
_________________________________________________________________________
E-mail address
Method of Payment:
Check
Money Order
MasterCard
Visa
AMEX
______________________________________________ _____________________
Credit Card Number Verification
Number (3-4 digit code)
_________________________________________________
Exp. Date: Month
Year
_________________________________________________________________
Card Holder’s Name