Name_________________________________________________________________
Agency________________________________________________________________
Address_______________________________________________________________
Email address_____________________________________
Total Amount Enclosed: ________________
Please make your check payable to: Judge David’s In-Service
Registration Fee: $45 per person ($65 after March 9, 2011)
Mail to: Brock Hesler
Witham Health Services
PO Box 1200
Lebanon, IN 46052
Please mail with Payment today!
One check per organization covering all individuals registering is acceptable; however, please include a separate registration form for each person attending, even if submitting only one check.
PLEASE NOTE: DUE TO OVERWHELMING RESPONSE IN PAST YEARS, REGISTRATION on the event date IS NO LONGER AVAILABLE.
You may also download a printable version of this registration form:
