Magic Palette & Skillet Workshops
10646 Glen Acres Dr. So.
Seattle, WA 98168
206-431-8227
APPLICATION / REGISTRATION FORM
NAME (as on Passport) ______________________________________________________________
ADDRESS: ________________________CITY________________STATE_________ZIP_____________
PHONE: ___________________________________CELL ___________________________________
EMAIL ADDRESS: ___________________________________________________________________
ACCOMMODATIONS
I am ordering the following:
( ) Dianna Shyne Susan Diehl Workshop - $2,995- Double Occupancy -- $3,500 - Sgl Occupancy (if available)
May 19-June 02, 2012 - Deposit: $500 by Feb15, 2012 / Full Payment by Mar 28, 2012
( ) Please assign a roommate, if possible
( ) I wish to share a room with_____________________________________________________
FORM OF PAYMENT
( ) CHECK ( ) CREDIT CARD - TYPE C/C_______ NO. ____________________EXP DATE ______
TRAVEL INFORMATION
If you have any dietary or medical restrictions, please list them here____________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EMERGENCY CONTACT NAME & NUMBERS
NAME:___________________________________________________________________________
PHONE NUMBER ___________________________________________________________________
DECLARATION
By signing this form you have read and understand and agree to the terms and conditions
NAME ________________________________________________________________________
DATE_________________________________________________________________________
Please send form to: MAGIC PALETTE & SKILLET WORKSHOPS – Attn: Bill Sperling
10646 Glen Acres Dr. So. - Seattle, WA 98168 - Tel: 206 431-8227
©2011 Magic Palette-Skillet Workshops
To Register, Fill out application include deposit and send by snail mail to:
MAGIC PALETTE & SKILLET WORKSHOPS
10646 Glen Acres Dr. So.
Seattle, WA - 98168
Phone: 206 431 8227 Cell: 206 229 6893
Email: williamsperlingg@aol.com
Web Site: www.magicpalette-skilletworkshops.com
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