Safety Whys - Registration

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Course Information:	Course Fee: $21.00 Pre-Registration is required. Registrations are on a first come, first serve basis upon reciept of application and fee. Complete the form at the bottom of this page and submit the course fee along with any fees for merchandise to complete your registration. Make checks payable to: SafetyWhys SafetyWhys P.O. Box 1177 Helotes, Texas 78023-1177 Call 210.695.9838 for more information.

Date:	3/27/10
Location:	Connally Memorial Medical Center
City:	Floresville, Texas, 78114

First Name:
Last Name:
Age:
Date of Birth:
School Attended:
Last 4 digits of SSN (student):

Name of Parent/Guardian:
Email Address:
Phone:
2nd Phone:
Address:

City:
State:
Zip Code:

	What is your career choice?

	Is your parent/guardian employed or a parishoner at the host institution? Yes No

	How did you find out about us?

	Would you like a t-shirt? Shirts are bright yellow with SafetyWhys logo. Available in Large or X-Large. Large (Add $7.00 to Course Fee) X-Large (Add $7.00 to Course Fee) Qty: