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Information / Enrollment Request Form

If you are requesting additional information, it is necessary to complete only the items in blue.
If you are requesting enrollment, please complete all items.
(Classroom space limited to maximum of 20 and minimum of 10 or class may be rescheduled.)

Student's Name - First, Middle, Last
Student's E -Mail Address
Student's Phone (715-000-0000)
Student's Address
City	State Zip
Parent/Guardian's Full Name
Municipality	of
County
Student's Social Security No.
Student's Date of Birth - mmddyy
Student's School
Student's Employer
Please check desired enrollment:
Course number or specify service:
Please list special circumstances related to enrollment (learning disabilities, disabilities, etc.):

Class time that best fits your schedule:
Payment method:
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Please note that our site is NOT encrypted. The information you send is not secured. If you would rather not send this form electronically, fill out all the information and go to the File menu and select Print to print out this form and mail to the address below.

Licensed by the State of Wisconsin

Phone 715.453.6008
Fax 715.453.8832

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