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Please print, fill out, and mail this
form (with a check made out to "Palo Alto Community Child Care")
to:
Beatriz Pastor
PACCC
3990 Ventura Court
Palo Alto, CA 94306
Please indicate date of
workshop in memo section of check.
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Please print clearly in
block letters. Thank you!
Name: ________________________________________
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Phone number: __________________________________
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Program/school: ________________________________
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Member? ________ Non-member?
__________________
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| Address: ______________________________________ |
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| ______________________________ |
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| Email: ________________________________________ |
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| Name of workshop: _____________________________ |
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| Date of workshop: _______________________________ |
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| Number of attendees: _____________________________ |
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| How many are members? _____________________________ |
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| Amount included: ________________________________ |
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Additional purchases
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| _______ Membership ($25) |
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| _______ Renewal ($20) |
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| _______ CPR $55 deposit |
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| Comments: ______________________________________________________ |
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Thank you for
registering for a workshop
with the Provider Connection!
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