Printable Registration Form

You may complete this form on your computer and print it from your browser for submission to our office.

Fax this completed form to: (815)744-8396   or Mail to:
2705 McDonough Street,
Joliet IL 60436
If you have any questions, call John at (815) 744-8337 or e-mail jsalzer@pdaonline.org
Method of payment is due prior to workshop.
Refund policy:      Refunds are made when cancellations are received seven days before the start of class or workshop.

Name of Participant: 
Social Security Number: - - **THIS FIELD MUST BE COMPLETED**

Home:

Address:
City: , State:   Zip Code:
Home Phone: ( ) -  
 Email Address: 

Position:

Teacher - Grade Level:     Administrator (title):
Secretary     Social worker    Other:   

School:

District Name: District Number:
School Name:
School Address:
City: , State:    Zip Code:
School Phone: ( ) -    Fax: ( ) -

Workshop/Grad Class Title:
Workshop/Grad Class Date:  Fee:  $
If you are taking a computer workshop/class, please indicate computer preference: PC    MAC

Workshop/Grad Class Title:
Workshop/Grad Class Date:  Fee:  $
If you are taking a computer workshop/class, please indicate computer preference: PC    MAC
Payment Options:
Option #1:

Credit Card (check one):     Visa     MasterCard
Credit Card #: - - -   
Expiration Date:    
Amount Applied:  $

Option #2:

Cash   Check  Check Number:   Amount: $

Option #3:

PO #:

_________________________________
(Please submit copy of P.O.)
Administrator's Signature

Billing Address: