Education & Training - Sign-up Form - Hearing Loss Academy - Hearing Loss Association of Delaware

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Hearing Loss Academy
Class Registration Form

HLADE FEIN# 51-0303157

Nane ________________________________________________________________

First

Last

Middle

Address: _____________________________________________________________

Street / PO Box

City   _________________________ State ___________________________ Zip _____

Phone - Home (         )   _______________    Phone - Work (         )    _______________

E-Mail Address:   ________________________________________________________

I would like to sign up for:__________________________________________________

Name of Class -- Beginning or Intermediate

Location:                 [     ] Wilmington        [     ] Dover

Date Class Begins:______________________ Time: _________PM

Cost of Class:___________________________________________________________

Payment (please check one):   [    ] I will send a check        [    ] I will Bring a check
                                                        [    ] I would like a payment plan

Invoice: ________________________________________________________________

	Agency	Amount	Contact:
State of Delaware employees must have their Supervisor's signature on the registration form to attend the class. MAIL OR FAX REGISTRATION FORM TO ABOVE ADDRESS OR TELEPHONE/FAX NUMBER.

Send this form to:
HLADE-Hearing Loss Association of Delaware
3204 Powhatan Drive Wilmington, DE 19808 Or Fax it to: (302) 292-3066 (Fax/Voice/Relay)

For more information, or to request classes to be conducted in your area contact us.

Hearing Loss Academy Class Registration Form

Hearing Loss - An Issue of National Health Concern

Hearing Loss Academy
Class Registration Form