Center for Creative Learning Course Registration Form

Fill out and submit this form to register for any course listed in "Course/Date" below.
For specific date details, see the calendar or click on More Info on a specific item below.

Course/Date*

Please select all
courses/events you wish
to attend; if you are
considering multiple
dates for a course, select
each consideration.

Course/Event	Specifics	Start Date
Vets Journey Home	Milwaukee, WI August 2010	August 20, 2010	More Info
Vets Journey Home	Houston Sept 2010	September 17, 2010	More Info
Vets Journey Home	Gaia Maryland Nov 2010	November 5, 2010	More Info

Will you be a participant or staff member?*

if staff, are you a veteran or civilian?

Gender*

First Name*

Last Name*

Occupation

Birth Date

(format m/d/yyyy)

Street Address

City

State

Zip

Home Phone**

(format 123-456-7890)

Cell Phone**

(format 123-456-7890)

Work Phone**

(format 123-456-7890)

Who referred you to us?

Please give us information about your service and goals, if registering as a participant

Branch

MOS

Have you served in Combat?

if yes, theater of action:

Dates of service

What is the outcome you would
like for yourself from attending
this program?

Other comments

Are you a human?*

(This helps us prevent
spam and bots)

*Required
**At least one telephone number is required