Community Health Education Class Enrollment Form

* You can register via this form, email, or in person at the VMH Community Health Educator's office, located (lower level) at the Vernon Memorial Hospital.
* Payment must be made prior to attending classes. Please make check payable to VMH.
* Class space may be limited, so early registration is encouraged. Registration is on a first-come, first-served basis.
* VMH reserves the right to cancel classes, programs, and events for insufficient enrollment. Guests will be notified only if a class is cancelled.
* Use one form per person (except for adult-child classes - one form per couple)
* Each participant prior to the first class sesson must fill out an informed consent form. (available from VMH heath educator)
* Questions? Call the VMH Community Health Educator, Angie Dahl, at (608) 637-4298

 

Name:

Address:
Street:
City:
State:
Zip Code:

Phone Number:
Alternate Phone:

Are You Employed By VMH?
Dept:
Phone Number:

Session start date: (such as "Mid-January" if date is not known)

Class Names and Fees: (name in left box, fee in right box for up to four classes)
$
$
$
$

Total Fees: $

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