Revised 12/17/2014
AHA Programs Registration Form
(Registration Deadline: One week prior to start of course)
Name: Sex: M F Date:
Address: County: ______________________________
City: State: Zip: ________________
Date of Birth: / / Race Code: ______
Grade Level Completed: Home Ph.: _________________________
Email: __________________________________________________________
Employer: Fax: _________________________
Business Ph.: Other: ________________________
Employer Address: _____________________________________
City: State: Zip: ________
CANCELLATION POLICY: You may cancel your reservations or reschedule up to one day prior to the course without
penalty. Due to the limited notice, all cancellations received less than one day in advance will NOT be refunded. To
cancel a course please e-mail aha@laniertech.edu, phone (770)531-6098 by 09:00 am the day before the course is to be
conducted. There will be no exceptions.
Name of Course: Date:
Location: Fee:
1.
2.
3.
4.
Minimum Class Size Policy: We always strive to conduct all scheduled courses. However, there may be times when
registration numbers will require us to reschedule. We apologize for any inconvenience!
Method of Payment
(Please check one)
Check # Cash Invoice – must provide P.O. #
MC VISA Discover Card# V-Code: Exp. Date:
Card Holder (Please Print): Date:
Authorized By (Name/Title):
Signature only needed for invoice and credit card payments.
How to Register: MAIL - Lanier Technical College, Attn: Training Center, 2990 Landrum Education Dr.
Oakwood, GA 30566; FAX – (770)531-6355; EMAIL aha@laniertech.edu
1 –
Native
American
2 – Asian
3 – African
American
4 – Hispanic
5 – White
6 -
Multiracial
