Fall Winter 2018-19

Registration Form

First Name

Last Name

Address

City

State

Zip

Home Phone

Email

Second Registrant’s Name (if applicable)

Home Phone

Email

Course Name

Course Code

Total Course Fee $

I would like to support The Center’s on-going community programs, enclosed is my tax-deductible donation: $

Total $

Payment Methods Credit Card

Visa Mastercard American Express

Discover

Name as it appears on Card

Card Number

Security Code

Signature

Expiration date

Check

Please make checks payable to Center for Continuing Education and mail with this form to 1000 West Boston Post Road, Mamaroneck, NY 10543