Use your computer's print command to print out a "faxable" copy of this form.
| Program / Workshop / Drumming Event: | |
| Place: | |
| Date & Time: | |
| Cost: | |
| Facilitator: | Jack Barnes |
Please complete the following:
All information provided will be kept in strictest confidence.
Name:
School Board / Other Affiliation:
Address:
City / Town:
Province:
Postal Code:
Phone:
Fax:
E-Mail:
Fax this form to : (519) 631-4819 or mail to the address above.
You will be contacted as soon as possible to confirm your registration.