dan st. romain

Cultivating Character in Kids
Course Registration Form

    Full Name:

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    Position:

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    Grade Level(s)
    or
    Age Group of Students:
    Please note if you work with Spanish speaking students

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    School/District:

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    City:

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    State:

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    Email Address:
    This email will not be shared or made public in any way. This will be Dan’s primary method of communication with you throughout the year.

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    Phone Number:
    This number will not be shared or made public in any way. It will be used as a secondary contact method.

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    Who will be paying for the course?
    My School/District/Agency

    or

    Me

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    Are you registering as part of a group or individual?
    Group

    or

    Individual

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    If you are registering as part of a Group, what is the name of the School/District/Agency responsible for payment? (If you are registering individually, please indicate N/A in the required field.)

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    If you are registering as part of a Group, who is the contact person coordinating the effort? (If you are registering individually, please indicate N/A in the required field.)

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    What method will be used for payment?
    Check, PayPal, Credit Card, Purchase Order

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