The Southern Flames present  Sara Sally LeGrand

Lottery / Registration Form

Name:                                                                                                                                    

Address:                                                                                                         

Telephone:                                                                                                      

Alternate Telephone (mobile):                                                                         

Email Address:                                                                                                

 Class Preference (check all that apply):

              Creativity and the Glass Corsage, January 21-22, 2011 (Friday/Saturday)

              Silvered Glass, January 24, 2011 (Monday)

    Waiting List

Do you want to be on the waiting list if your name is not drawn for a class session (circle one)?  yes    no

FORM and CHECK

Please print out, complete, then mail the completed form and your check in the amount of $300.00 (Members) or $325 (Non Members) for Creativity and the Glass Corsage and/or $180.00 (Members) or $205 (Non-Members) for Silvered Glass  made payable to “Southern Flames” to:

Southern Flames

c/o Martha Fuerst

2679 Mercedes Drive NE

Atlanta, Georgia 30345-3974

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For Southern Flames Administrative Use Only  Please do not fill in below

Received On _________   Check # __________

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