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REGISTRATION INFORMATION
* Required Fields	Complete and return this form electronically.
You have the option to register and pay online or register online and pay by mail: When paying online, will be notified in 3-5 business days of class confirmation. Online payment is processed through a secure, encrypted server. When registering online and paying by mail, your space in class will be held for two weeks after we receive your online registration. If payment is not received within two weeks of registering online, your space in class will be forfeited and you must re-register. Send payments to: Potomac Hospital Community Education Department, 2300 Opitz Boulevard, Woodbridge, VA 22191.
*First Name:	MI:
*Last Name:
*Gender:	Male Female
Name of person attending with me:
*Address:
*City:
*State:	*Zip Code:
*Home Phone:
Work Phone:
*Email:
Due Date (if applicable):

*Enter class name and date. Please give child's name and date of birth for Safe Sitter Classes.


PAYMENT INFORMATION
Please select registration option:
Register/Pay By Mail (or for free classes) Register/Pay Online

Credit Card Billing Information
*Name:	Note: This must be the name exactly as it appears on your credit card.
*Address:
*City:
*State:	*Zip Code:
*Home Phone:
*Credit Card Number:
*Credit Card Type:
*Expiration Date:	*Year:
*Amount to be charged to credit card (Cost of class):

This page was last updated on January 27, 2010