Course Registration Form

Student Registration Form
Student Name *

First Name Last Name Suffix
Gender
Address

Street Address

Street Address Line 2

City State

Zip Code
Student E-mail
example@example.com
Mobile Number
Home Phone Number
Are you a returning citizen (recently released) *

Yes No

Returning Citizen
Courses *
How long were you gone? Years Months blank*
How long have you been home? Years Months blank*

Payment
Choose your class
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Beginner Computer Class
$ 75.00

Microsoft Word
$ 75.00

Microsoft Excel
$ 75.00

Make it a private class One on One sessions tailored to fit your individual needs.
$ 75.00

Total

$ 0.00

Submit

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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