First Name: Last Name:

Mailing Address:

City: State: Zip code:

Email Address:

All persons to participate from your family:

Total number adults: Total number of children:

Adult Names:

Children's names and age:

1. Name: Age:
2. Name: Age:
3. Name: Age:
4. Name: Age:
5. Name: Age:
6. Name: Age:

Check all the following that apply:

Registration Fee ^*Info Options:

 N/A $10.00 before August 1^st

$15.00 after August 1^st

$20.00 at the door

$15.00 additional, for the Workshop with Elaine Davies Thomas
Jefferson Education (optional)

Total amount $ Pick One $15.00 $20.00 $30.00 $35.00

Payment Methods

Call to pay with a credit card. Call 530-347-2200 (Monday-Friday 9am-5pm)

Credit card info included with registration form

    VISA

    MASTERCARD                                                                       

Name on Card:

Card Number:

Expiration Date: Zip Code

3 digit number on back:

Send a check with registration form via US Mail

Check amount included $

or print and mail.

Registration instructions:

This form allows you to complete the form right on your computer then you can print and mail; copy and past it to an email or just push the submit button.

• If you want to send the form electronically complete the form then push the submit button or copy and past it to an email and send it to customeducation@yahoo.com.
• Or you can complete the form on the computer and print it using your internet browsers printing application, then mail it to:

Homeschool Resource Center P.O. Box 1090 Cottonwood, CA 96022

To print, you may push the file dropdown menu from your browser window, find and select the print option listed.

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Questions? Email customeducation@yahoo.com

*Registration fee is only to cover expenses for the conference.  No staff or individual will receive funds for this conference.  Expenses include: Deposit for facilities, newspaper advertising and children’s craft and paper supplies.

Registration fee is per family, One registration form per family.

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