Coupon Workshop Registration

Name *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code United States Country

Phone Number *

### - ### - ####

Email *

Emergency Contact Person *

Phone Number *

### - ### - ####

Release Statement *

I have read and agree to the terms of the Release Statement.  If you are under 18 a guardian must sign a release form the day of the workshop.

Type of Class *

Ring   Oxy/Ace   Stick   MIG

First Choice Date/Time *

1 2 3 4 5 6 7 8 9 10 11 12 MM / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 2012 2013 YYYY

AM   PM

Second Choice Date/Time *

1 2 3 4 5 6 7 8 9 10 11 12 MM / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 2012 2013 YYYY

AM   PM

Are you a part of a group? Please list their names.

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