The Southern Flames presents 

Jennifer Geldard

October 6,7 & 8,9  2011

“The Art of Play, Surface Design , Form and Structure”

Registration Form

Name:                                                                                                                                      

  Address:                                                                                                                                  

 Telephone:                                                                                                                               

Alternate Telephone (mobile):                                                                                                    

Email Address:                                                                                                                        

Class Preference (only check one):

               Only able to attend Thursday/ Friday  (Oct 6/7)

               Only able to attend Saturday/Sunday  (Oct 8/9)

              Can attend either session, prefer Thursday/Friday -You may be placed in either class.

               Can attend either session, prefer Saturday/Sunday – You may be placed in either class.

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

 Please print out and complete this form.  Mail the completed form and your check in the amount of $ 350.00 made payable to “Southern Flames” to:

Southern Flames,Inc

c/o Camille Simmons

2154 Briarwillow Drive N.E.,

Atlanta, GA 30345

NOTE:  IF CHECKS AND FORMS ARE BEING MAILED THEY MUST BE RECEIVED BY July 12, 2011.

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

Received On _________   Check # __________

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