Course Registration Form
Course Name:   Course Name:
Course Date:   Course Date:
Course Location:   Course Location:
Course Name:   Course Name:
Course Date:   Course Date:
Course Location:   Course Location:
Your Full Name: Profession:
Street Address: Employer:
City: License:
(required for lab courses)
State: Zip Code:
Home Phone: Work Phone:
Email:
Required for confirmations

Cell Phone:
Required for last minute schedule changes
Comments:
(If you wish to order required or recommended materialsfor a course, Please indicate yourinterest to do so here)
Please check all that apply: Contact me about becoming a Co-Sponsor or Partner.
Please mail me the Brochure for the Seminar I have selected.
Payment Method:
(NOTE: Tuition amounts differ depending on course. Please refer to Program Brochure or online listing) 		I will mail a check within 24 hours.
I will call in with Credit Card information on next business day.

Send Form to:
Education Resources, Inc.
266 Main Street
Suite #12
Medfield, MA 02052
or
Fax: 508-359-2959

Education Resources, Inc. reserves the right to cancel any course due to insufficient registration or extenuating circumstances. Please do not make non-refundable travel arrangements until you have called us and received confirmation that the course will be held. We are not responsible for any expenses incurred by participants if the course must be cancelled.

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