VicenteOnline

REGISTRATION FORM

Name: ______________________________________________________

Address: ____________________________________________________

____________________________________________________________

Phone: (H) ______________________ ; (School) _____________________

(Cell) _________________________; Personal E-mail: ________________________

Are you a Spanish or Bilingual teacher? ______ Spanish; ______ Bilingual

Which language do you teach (for LOTE Teachers)? _________________

How did you learn about this program? ______________________________

___________________________________________________________

Program Title and Schedule: _______________________________________

Signature: _________________________ Date: _________________

Please send this form with your check for $155.00 (registration + January), payable to VIC Languages to the address below:

VIC Languages P.O. Box 172201 – Arlington, TX 76003-2201