Continuing Education Registration Form

Complete this form and click "Submit" below to register online, or .....

Make a copy of the completed form and mail to:  St. Bernard's, 120  French Road, Rochester, NY 14618   

Last Name:      
First Name:    
Address 1:      
Address 2:     
           City:       State:    Zip:
Parish Name:      City:

Ministry Title:

Day Phone:      Ext:
E-mail:          
 

Please check appropriate box(es):           

Billing Instructions:  

(There is only a fee for IT classes when the course is used for the Certificate Program at St. Bernard's)

      
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 numeric choices for month and year)
Name on Card:
 
 

Bill parish
Parish:  Parish Address:
    City:                  State:      Zip:   

(even if no payment is being made, please enter numeric choices for month and year for expiration date; fields cannot remain blank)