Registration Request Form

(Please cut along dotted lines & mail to: Augusta Adult & Community

Education, 33A Union Street, Augusta 04330)

Use this form to enroll in Augusta Adult and Community Education courses. You are

enrolled as soon as we receive your complete registration form and fee. You will

not be notified unless difficulty is encountered. (Please print)

Name (Last)_____________________ (First)____________ Date________

Address_______________________________________________________

Phone (work)___________________ Phone (home)____________________

Course Name Night* Fee

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

*Please indicate night, if offered more than one night. Check if senior citizen discount o

For office use only

Make your check payable to:

Augusta Adult Education

Total Enclosed: $_________________