registration

Please provide your complete name, address, and phone number.

Name If family is attending # in family:

Street Address # of children: under 12 yrs:

Address (cont.) under 3 yrs:

City State Zip

Work Phone Home Phone

E-mail

Please provide the requested program(s) and date(s).

DATE REQUESTED
PROGRAM DESCRIPTION *

PLEASE SELECT A PAYMENT OPTION BELOW:

Non-Refundable DEPOSIT OF $25 per adult program

or FULL AMOUNT

Tax Deductible Donation for scholarship fund enclosed

Total Amount Enclosed

Special Information: (Request for accommodation with another resident, dietary needs, bus or train information if pick-up is needed)

Please print out this page and send it, along with your check to:

Make all checks payable to:	PYRAMID LIFE CENTER
Mail to:	*Pyramid Life Center*
	*Paradox, NY 12858*

OFFICE & REGISTRAR:	Phone: (518) 426-4284 (Until June 24)
Pyramid Life Center	(518) 585-7545 (After June 24)
Paradox, NY 12858	E-Mail: monicaplc@aol.com

*Please note arrival times for programs is 4:00 PM or after

Name	If family is attending # in family:
Street Address	# of children: under 12 yrs:
Address (cont.)	under 3 yrs:
City	State Zip

Work Phone	Home Phone
E-mail

Please print out this page and send it, along with your check to:

Precision Pixel Graphic Design Copyright © 2008 Pyramid Life Center. All rights reserved. Revised: 3/08

Precision Pixel Graphic Design
Copyright © 2008 Pyramid Life Center. All rights reserved.
Revised: 3/08