Certification Program

Fall 2006 Registration Form

Register by one of three ways:

• Complete this form and click "Submit" to register online

• Fill out this form, print, and mail with payment (check payable to "St. Bernard's" or credit card information)  to:  St. Bernard's, 120  French Road, Rochester, NY 14618 Attn: Registrar

•  Register in person by bringing a copy of the completed form to the Academic Office along with check or credit card

Last Name:      
First Name:     Middle:
Address 1:     Apt: 
           City:       State:    Zip:
Home Phone:    Work Phone:   Ext:
E-mail:  
Category:      
        Certificate Candidate          Certificate Area:
        Master Catechist 
        Personal Enrichment (non-certificate)      Audit  Credit

Please check appropriate box(es):

Billing Instructions:                               

      
Select American Express Discover Master Visa
Acct #    Exp. Date:  Mo 01 02 03 04 05 06 07 08 09 10 11 12   Yr 03 04 05 06 07 08 09 10 11 12
 (even if no payment is being made, please enter choices for month and year)

Name on Card:
 
                 
Bill parish 
        Parish:              City: