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REGISTRATION FORM
Name_________________________________________________________________
Agency________________________________________________________________
Address_______________________________________________________________
Email address_____________________________________
Daytime Phone_____________________
Please make your check payable to: Judge David’s In-Service
Registration Fee: $45 per person ($55 after March 14, 2010)
Mail to: Pat Isenhower
Witham Health Services
PO Box 1200
Lebanon, IN 46052
Please mail with Payment today!
One check per organization covering all individuals registering is acceptable; however, please include a separate registration form for each person attending, even if submitting only one check.
PLEASE NOTE: DUE TO OVERWHELMING RESPONSE IN PAST YEARS, REGISTRATION on the event date IS NO LONGER AVAILABLE.
Total Amount Enclosed: ________________
You may also download a printable version of this registration form:
[CLICK TO DOWNLOAD]
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