Registration Form
First Name _________________________  Last Name _________________________

Home Address ____________________________________________________________

City ____________________  State _______________  Zip __________ - ______

Day Phone ________________________  Evening Phone _______________________

Email Address _____________________________________

Complete the class name and indicate the course number for your first
choice and alternates. If no alternates are listed for a class and the
class is full, you will be placed on the waiting list for your first
choice.

 * Minus $5 Early Bird Discount if registered 7 days in advance:_______________

                                             TOTAL FEE ENCLOSED _______________

METHOD OF PAYMENT

_____ Authorization, Purchase Order(Walk-in Registration only)

_____ Check # ____________________ -- Payable to "Adult Education"

_____ Visa/Mastercard ____________-____________-____________-____________

      Expiration Date _____ / _____  Name on Card _______________________

      Signature of Card Holder __________________________________________


* Payment in full for ALL courses is required at the time of registration.
* Registrations may be processed by mail, fax, phone or in person. Please note the registration
  process information to determine which will work best for you.
* In the event the class(s) do not meet the minimum enrollment, the course will be canceled.
  You will be notified and a refund will be processed.

Print out this page, fill out the form, and mail it along with your check to:

MCPS Adult and Continuing Education
310 South Curtis Street
Missoula, MT  59801

Or fax it to:  (406) 523-4000