Nashua Center

For the Multiply Handicapped, Inc.

PO Box 1269 • Nashua, NH 03061 • (603) 883-6163

Fax (603) 881-7198

Course Registration Form

Name: __________________ ______________________

First Last

Address: ______________________________________________

Number Street

_______________________________________________

City

_______________________________________________

State Zip Code

Telephone: _______________________________________________

Age: _______________________________________________

Work: ________________________________________________

Volunteer at: _______________________________________________

E-Mail: ________________________________________________

Contact Person: _____________________________________________

Telephone: _________________________________________________

Session attending: Spring Fall Winter

Signature: ___________________________Date: _________________