The Southern Flames present  Sara Sally LaGrand

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) FILLED

              Silvered Glass, January 24, 2011 (Monday)  FILLED

              Silvered Glass, January 25, 2011 (Tues) 

    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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