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A-B Community Education Registration Form
Student's name
________________________________________________
Grade (Fall'08) _______ Age
___________
Street & #
____________________________________________________
Town ______________________________
Zip________________
Phone _______________________ (evening)
____________________ (day)
email address
______________________________________________
Course Code: _________________ Course Name:
__________________________
Course Code: _________________ Course Name:
__________________________
Course Code: _________________ Course Name:
__________________________ Course Code: _________________ Course
Name: __________________________
Total $______________________
Charge to my Visa ___________ Mastercard
______________Discover__________AMEX____________
Account #
___________________________CID#________________
(last 3 numbers on signature
strip on back of card)
Cardholder Name (Print)
_____________________________________
Exp. Date ____________________ Signature
__________________________________________
Copyright © Acton-Boxborough Regional
School District. All rights reserved.
Last updated: August 20, 2008