Registration Form

AUGUSTA ADULT AND COMMUNITY EDUCATION - COURSE REGISTRATION

Name:__________________________________________________________Date:________________

Address:_____________________________________________________________________________

Telephone:(Work)_______________________(Home)____________________

(Cell)________________E-mail______________________________________

How did you hear about our program? _____________________________________________________
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COURSE TITLE:                                                                                 NIGHT:                                  FEE:

_____________________________________________________________________________________

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Senior Citizen?   Yes    No                  Make Check Payable to:  Augusta Adult Education

Credit/Debit Card number: __________________________________

Expiration Date: ____________________   CVV Code: ____________