Registration Form

 

   Name:      First* _________________________   Last* __________________________

   Address:  Street* __________________________________________  Apt.__________

                 City*__________________________________Zip*____________

 

   Home Phone (_____)_________________  Cell Phone (_____)_________________

   Email _______________________________________________

 

   Preferred Class Day:    ____ Saturday    ____ Sunday    ____ Monday

   Preferred Language:    ____English     ____Spanish    ____Russian   ____ Chinese

 

   Comments:_______________________________________________________________

   __________________________________________________________________________

   __________________________________________________________________________

 

    Attached is my check to cover:

Registration Fee($50.00):_____   Full Course payment (incl. registration fee) ($130.00):_____

 

 

 

 

 

Please mail this form along with your check or money order payable to LSCS:

Life Support Certification Specialist, P. O. Box 2073, Brentwood, CA 94513-9073

 

 

Filelds marked with * sign—required filed