PROGRAM REGISTRATION FORM

Please PRINT, complete, and return this form with check or payment information to:
Global Source Education: PO Box 11316, Bainbridge Island, WA 98110
or FAX to 206-780-5797

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$195	Farm Hands Afterschool Program Tuition Session 1: January 11-February 11 (this session has been cancelled) Session 2: February 22-March 25 Option 1: Mondays & Wednesdays, 2:30-5:00 Option 2: Tuesdays & Thursdays, 2:30-5:00
$5/Day or $35/session	Farm Hands, extended care option (5-5:30p)
$35	Global Source Membership/Contribution
$_______	Tax Deductable Contribution to Global Source Education
$_______	Total Amount Due
Date of Registration
Name (First – Last) Child/Parent
Mailing Address
Day Phone
E-Mail
School/Organization

Grade Level

Notes

You can register by phone during office hours at 206-780-5797
Please make checks payable to: Global Source Education
Credit Cards (Visa or MasterCard) accepted
Credit Card Information    MasterCard     Visa    Exp Date ____/____
Credit Card Number    __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Signature  ____________________________________