CREATIVE ESCAPE WORKSHOPS REGISTRATION FORM       

Please print and mail this form with payment  to:

Creative Escape Workshops, 1489 Schaeffer Road, Sebastopol, CA 95472.

To pay  by phone (707)824-1811

 

WORKSHOP TEACHER/ARTIST NAME: ­­­­­__________________________________                 

Workshop Dates_________________  

Workshop location___________________________________________

Name: ­(Mr./Mrs./Ms.)________________________________________________________________

Address: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___________________________________________________________________________

CITY_______________________________________________________________________________

STATE______________ZIP____________________COUNTRY__________________________

Phone (home) ____________________________________________________________________

Phone (cell - so we can reach you on the road if necessary_________________________________

email___________________________________________________________________

      I am enclosing Deposit only (50% tuition)                   Payment in full                     2nd payment/ Final installment

Registration in a workshop indicates that you have read and accept the terms and conditions .

Payment

       Check  enclosed  (payable to Carolyn Wilson/Creative Escape Workshops)

or

Authorization to charge my credit/debit card (Visa/Mastercard/Discover/American Express)

 Card Number ________________________________ Expiration (month/yr)________________

CCV____ Authorization signature______________________________________ Date_________

or

Pay by phone - call (707)824-1811