In-Service Registration

 

 

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:

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