Registration - Info Request Form

Registration / Information Request Form

**Please use the form below to register for an upcoming course with Manning Emergency Educators.**

To register, please submit this form online or print and send it to us. Enrollment is on a first-come, first-served basis. You will receive confirmation of enrollment upon our receipt of all the necessary documentation and/or fees.
To print this form, simply fill in as much information as possible and click the continue button for a printable copy.
Individual's Name:	Business / Organization:		Street:
City:	State:		Zip:
Telephone Day:	Telephone Evening:		Best Way To Reach You:
Email:	Other Contact Info:

My interest is in: (Ctrl-Click to select multiple courses)		On the following Dates:	(View Current Course Dates)
I am:
I have a question about:

Financial Information...

If you are paying for yourself - in part or in full, a non-refundable fee is required along with this registration (see individual course descriptions for advance fees required.)

Payment Submitted: Check Number: Date

If your organization/business will be paying in part or in full, please have the appropriate official complete the following:

% of Course Fees to be billed:

Organization/Business Name:

Authorization by: Position:

Authorizing Signature:________________________ Telephone:

Email: Fax:

Billing Address:

City: State: Zip: