Form 08-1466 - Training Registration Form

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TREET CITY STATE ZIP
G
irl Scouts Central Maryland
4806 Seton Drive
Baltimore, MD 21215-3247
T 410 358.9711, 800 492.2521
F 410 358.9918
TRAINING REGISTRATION FORM
THIS FORM MUST BE RECEIVED AT LEAST 2 WEEKS PRIOR TO THE TRAINING EVENT.
Please print all information. Please make copies of this form if needed.
Name (Last, First, MI): _________________________________________________________________________________
Address_____________________________________________________________________________________________
City ____________________________________________State _______________ Zip Code ________________________
E-mail Address: ______________________________________________________________________________________
Telephone: Home __________________________ Work ________________________ Cell
_ ________________________
Service Unit #_____________ Troop #____________ Position:
Leader
Co-Leader
Other __________________
Senior
Ambassador
Grade Level:
Daisy
Brownie
Junior
Cadette
TRAINING CHOICES: PLAN AHEAD. CLASSES FILL QUICKLY.
*Indicate alternate training choice.
st
1
Course Name: _______________________________________ Location: _______________________ Date: __________
Alternate Choice :_______________________________________ Location: _______________________ Date: _________
nd
2
Course Name: ______________________________________ Location: _______________________ Date: _________
Alternate Choice : ______________________________________ Location: _______________________ Date: __________
Please list any special needs, i.e. accessibility, dietary, etc.
FOR FIRST/CPR/AED REGISTRATIONS ONLY
Mail Registration and Payment to:
Please enclose payment for the First Aid/CPR/AED
Adult Learning Services
Course in the amount of $5 .00
Girl Scouts of Central Maryland
Check # _________enclosed (make payable to GSCM)
4806 Seton Drive
Credit Card:
MasterCard
Visa
$_____________
Baltimore, MD 21215
Account #: _______________________________________
Exp. Date ____________ Security Code________________
(Security Code is the 3 digit code on the back of your credit card)
Cardholder
: _______________________________
(Print Name)
Address: __________________________________________
City: _____________________State: ______ Zip:__________
Home : __________________Work : _____________________
Cardholder Signature:________________________________
08-1466
-201

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