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Event Registration
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Event Registration


To register for a class or event, complete this form entirely. We will process you registration and either call or e-mail you confirmation.

 

PLEASE NOTE: You are not registered for a program until you get a confirmation. If you don't receive phone confirmation within 3 business days, please call 859-625-3446 to register.

 

NOTE: Please complete a registration form for each person attending a class or event.


Today's Date

*

Class or Event Title

*

Class/Event Date

*

Name

*

Street Address

*

City

*

Telephone

E-mail

How did you hear about this class or event?

Health Vision Newsletter
Pattie A. Clay Web site
Friend
Richmond Register Newspaper
Doctor
Other

Gender

Male
Female
Both
*

Age


Please enter the characters seen in the image below.