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Class Registration Form

 

Please complete the form below and press the submit button. You are not officially registered until you receive an e-mail confirmation from Providence. If there is a fee associated with the class, you will receive payment instructions via standard mail. If you have any questions about your registration, or do not receive an e-mail confirmation from us within 3 business days, please call (360) 493-7768. 

First Name

Last Name

Address

City

State

Zip

Daytime phone 
with area code

Evening phone 
with area code

E-mail

Date of birth

Title of class

High Blood Pressure
Fitness After 55
Diabetes Exercise Class
Look Good Feel Better

Date & time of class 
(if listed)  

Number of attendees

1
2
3
4
If more than one attendee, please list your companion's:

First Name

Last Name

Phone

Date of Birth