Student Registration

Chameleon Academy of Communication and Civility Registration/Contract Form

Company Name

Date

Month Day Year

Address

City/State

Zip Code

Preferred Class Date

Month Day Year

Class Type

Email Address

Classes Preferred

List the class you are interested in

Training Start Time

Training End Time

Preferred Class Location

At Chameleon Academy Offsite (Another location)

Guaranteed Number of Class Participants

For groups only

Contact Name

Last

First

City

State

Zip Code

Phone Number

Fax Number

Location Address (If Off-Site Location is Chosen)_

Street Address

Street Address Line 2

City

State

Zip Code

Location Address (For Off-Site Locations Only)

Street Address

Street Address Line 2

City

State

Zip Code

Chameleon Academy of Civility and Communication Contract cont.

Emergency Contact 1 (For individual registration for children and adolescents only)

Last Name

First Name

Primary Phone Number

Secondary Phone Number

Please list any food allergies

Complete this for dining etiquette classes only

Room Set Up

Please describe the set up of the room

Speaker Fees (Please ask for an email quote prior to completing this amount. A deposit of 50% of the speaking fee is due with the submission of this signed contract. The remaining balance is due (at the time of arrival to the location and prior to the beginning of the presentation.)

Total Speaker Fees

First Name

Secondary Phone Number

Travel Fee amount agreed upon( A quote of travel fees will be provided to you via email. This amount must be paid in advance by the company prior to the arrival of the presenter).

Please list any additional details for the training in this box.

Please sign the contract below. This contract is void if not signed and returned with a deposit of 50% within 48 hours of the available date being confirmed. Dates can only be held with deposit.

Media Interviews may be granted prior to or at the conclusion of the presentation. Photographs may be taken during the presentation, however, audio and video recording of presentation is prohibited.