Family Partnership Agreements

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Family Partnership Agreements Enrollment Form

Required Items. Please read the cancellation policies.

Student Information:

1st Student Name:

1st Student Email:

2nd Student Name:

2nd Student Email:

3rd Student Name:

3rd Student Email:

Agency Information:

* Agency:

Contact Name:

* Job Title:

* Phone:

Fax:

Address:

City:

State:

Zip:

Course Information:

* Course:

* Number of Students:

Course Cost:

$425.00 per person

* Fees:

Discounts:

Take 3 Discount (For groups of 3 or more - Deduct $25 per person)

Discounts:

Early Bird Discount (See Deadline Dates Listed above - Deduct $25 per person)

Note:

Early Bird Discounts are for those that pay on or before deadline date listed above. When booking online, Take 3 discount is for 3 or more student registering for the same workshop.

* Total Fees:

Classes are occasionally cancelled. Please indicate if there is a second date in our schedule which may be acceptable to you. You will not be enrolled in this class without a confirmation by phone and/or email or fax. Please read the cancellation policies.

Alternate Course Date::

Payment Method:
* Payment Method:	PO#:
	Please bill the company: letter of authorization or purchase order will be faxed to (901) 758-4036. I have read and understand the cancellation policies for HSU courses.
Card No:
Expiration Date:
Security Code:	(3-digit security code on back of card)
Name on Card:
Authorizing Manager:
Comments:
Payment Method:

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HSU provides a range of services to allow persons with disabilities to participate fully in educational programs and activities. If you desire support services, contact the student Access Center at (901) 758-4034.

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