SMMC_CommEd Registration Form

SMMC-Community Education REGISTRATION FORM

Mail it to: SMMC
Community Education Dept.
1 Hospital Dr
Lowell, MA 01852

Print out this Form,
Complete and mail with your check
Make payable to "SMMC"

This form is provided by S.A.F.E.

Questions?, call: Community Education at 978-934-8437

Participant's name (First)________________________(Last) ________________________

For multiple participants in one program add names below:

Participant #2 name (First)________________________(Last) ________________________

Participant #3 name (First)________________________(Last) ________________________

Street & # ____________________________________________________

City/Town ______________________________ State ________ Zip Code________________

Phone (evening)_______________________(day) ____________________ (cell) _________________

email address ___________________________________ {Registration is confirmed via Email}

Unless otherwise posted, classes are held in: Conf. Rm 1, SMMC, 1 Hospital Dr, Lowell MA 08152

Indicate desired program by placing a value in the Qty column and calculating the Extended Price.

I have read and understand the S.A.F.E Refund Policy, my check for the Total amount is enclosed.

Signature __________________________________________ Date: _______________