P. O. Box 872188
Wasilla, AK 99687-2188
907-376-0366 (Office)
907-376-0966 (Fax)
Name: _____________________________________________________
Organization: _______________________________________________
Mailing Address: _____________________________________________
City, State & Zip Code: _________________________________________
E-mail Address: ______________________________________________
Phone: ______________________________________________________
Training (Title): ______________________________________________
Date (s): ____________________________________________________
Dietary or Other Special Needs: __________________________________
Cost: $ (enclose check & mail to above address). One form per person, please. Confirmation will be sent.
Scholarship needs: (Please Explain) ______________________________
Non-refundable deposit of $50 is required to hold your seat. It will be deducted from your registration fee.
Please print and mail in if you have a web based e-mail account. (yahoo, g-mail, etc)
Please call: 907-376-0366 if you have any further questions. If you will not be able to attend the workshop on the scheduled day, call: 907-355-6692. Thank you