The Umbrella
Event Registration Form

Name of Event:

Name of person registering:

Company/Organization:

Address 1:

Address 2:

City:     State:       Zip:

Business Phone:     Cell Phone:

Email:

Number of people attending:

Names of persons attending:

Cost of event (if applicable):

Will attendees be needing CEUs?  yes          no

___________________________________________________________________

Payment Method: 

please bill me (continue with on-line registration)

check enclosed (print page and mail registration form to: The Umbrella, Special Events, PO Box 658, 435 East Main Street, Ansonia, CT 06401)

credit card (print page and mail registration form to: The Umbrella, Special Events, PO Box 658, 435 East Main Street, Ansonia, CT 06401)

Credit Card number:__________________________________________________

Where did you learn about our event?: