ENRICHMENT COURSE REGISTRATION FORM 
 Please Note: This is not an electronic form. Print this form and complete it by hand. Complete one form for each person.  Register in person, by telephone (823-4299),  fax (892-4367), or mail form to:   
Norwich Adult Education, 182 Cedar St., Norwich, CT 06360
Please Print

FIRST
NAME

LAST
NAME

ADDRESS

CITY

STATE

ZIP

PHONE (Day)

PHONE (Eve)

EMAIL

Class1#                    

 Title Start 
Date

Class 2 #

 Title Start 
Date
Class 3 # Title Start 
Date

                                                          CLASS FEE(s) 
(Norwich Senior or Disabled - 25% discount)

 Class 1

Class 2

Class 3
     

NON-NORWICH RESIDENTS ADD $5
per class except where noted otherwise

 

    

FOOD FEE  if applicable, non-refundable

 

    

SUBTOTAL

      

GRAND TOTAL 

 

Check One:         MASTERCARD      OR             VISA

CARD#___________-___________-___________-___________

EXP. DATE   ____________/____________/____________

SIGNATURE

FOR OFFICE USE ONLY:

PAID BY:

CHECK #

CC

CASH

AMOUNT  $

DATE