Class Registration Form
For registration information please follow the new instructions.
Please print this form. Complete and mail with payment to:
Welch Education
2024 E Monument St, Suite 1-1200
Baltimore, MD 21205.
If you have questions, please call 410-614-3035. Registration is limited so please register early.
| Name: (first, middle initial, last) |
________________________________________________ |
| Social security number: | __ __ __ - __ __ - __ __ __ __ |
| Daytime phone: | __ __ __ - __ __ __ - __ __ __ __ |
| Evening phone: | __ __ __ - __ __ __ - __ __ __ __ |
| E-mail address: | ________________________________________________ |
| Campus Addresss: | ________________________________________________ |
Please check your affiliation and status:
SOM __ | SPH __ | SON __ | JHH __ | Homewood __ | Eastern__ |
Mt Washington __
|
Other_______________
Faculty __ | Staff__ | Student__ | Resident/Fellow __ | Other______________________
| Date | Course No. & Sect. | Course Title | Tuition |
|---|---|---|---|
| $ | |||
| $ | |||
| $ | |||
| Total: | $ | ||
Credit Card information:
____ Please charge tuition to credit card: _____ Visa ____ MastercardCard
# __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ Exp. Date: __ / __
Name as it appears on card (please print) _______________________________
Signature: ___________________________________ Date:________________
Fax: 410-614-3810 (for Free classes and credit card registrations only)