Porcelain Art Seminar Registration Application

First Name:    *    (Asterisks indicate required fields.)
Last Name:   *
Address:   *
Address:
City:   *
USA International
State:   * Zip Code:   *
Country (Outside U.S.):
Email Address:   *
Telephone:   Emergency Contact Phone:  
Contact Person's Name:
Contact's relationship to you:
Do you wish assistance in locating a roommate for seminar?
Do you prefer a smoker?
Are you registering as a resident student or day student?  
If day student, are you attending the Graduation dinner?
Pick your preferences of teachers' in order 1st thru 5th choice. 1.  
  2.  
  3.  
  4.  
  5.  
If all classes are filled - do you wish to be on the stand-by list? Comments:
  
Thank you.  

Make a check payable to CBC Porcelain Art Seminar for the $30 deposit.

Send Registration form with the "Send Application" button above and mail the check.
  OR
Print out the registration form and mail with the check.

Mail To:
Shirley Kibler
CBC Porcelain Art Seminar Coordinator
Visual Arts Division
Coastal Bend College
3800 Charco Rd.
Beeville, TX 78102

E-Mail:  kiblers@fnbnet.net

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