Community Classes Registration

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Country (other than US):

Telephone Number

:Email address:

Course Title:

Course Date:

Credit Card Information: Visa or Mastercard only
If you are paying by credit card, please phone Aileen Donovan with your information or print this form and mail with credit card information to:

Send checks to:

Naropa Oakland/UCS, Registrar
Aileen Donovan
2141 Broadway
Oakland, CA 94612
510-835-4827, ext. 19

Type of card:

Visa MasterCard

Credit Card Name:

Credit Card Number:

Expiration Date:
(Month & Year)

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