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1REGISTER ONLINE AT
If faxing or mailing the registration form, please complete one registration form per student and class.
Photocopy as needed.
Student Information
Student Name:
____________________________________________________________________________________
Course Name:
Course Location:
___________________________________
________________________________
Course Date(s):
____________________________________________________________________________________
Facility Information
Facility Name:
_____________________________________________________________________________________
Mailing Address:
___________________________________________________________________________________
Where the invoice will be sent if paying by check.
Work Phone:
Work Fax:
___________________________________
_______________________________________
Facility Email: ____________________________________________________________________
Where the course confirmation will be emailed.
Sign up for our mailing list!
Make checks payable to
MCD Communities
Please email me the MCD Communities Course Schedule when it is
released every 6 months! (I am not currently on your mailing list.)
Please return the
completed
Please take me off your mailing list. Thank you!
registration form with
payment to:
Sharon Wyman
MCD Communities
Method of Payment
Assistant to the Division
All payment must be received prior to the start of the course.
Director
Pay by check.
11 Parkwood Drive
Pay by credit card.
Augusta, ME 04330
Tel: (207) 622-7566 x-240
Name on card: ____________________________________
Fax: (888) 974-1186
Email:
Credit card #: _____________________________________
CVV # (3 digit number on the back of the card): __________
Expiration date: __________
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