HOOPHOLE Mail Registration Form


PRINT OUT THIS FORM

Thank you for HAND PRINTING your responses!

Date ___________________

First and Last Names ______________________________________________________

Street Address ___________________________________________________________

City, State, Zip Code _______________________________________________________

Daytime Phone (area code first) __________    _______________________

E-Mail Address __________________________________________________________

Choice of Payment  (check one)  __credit/debit card   __personal check   __money order

If paying by personal check or money order, please make it payable to KohlQuest. Mail your check and completed registration form to: KohlQuest, 3271 Polk County Line Road, Rutherfordton, NC 28139.

If paying by credit/debit card, check which card:  __ MasterCard  __ Visa   __ American Express   __ Discover
Card Number _____________________________________________________________
Expiration Date (mmyy)   month _________  year _________
3-digit security code on back of your credit card in the signature strip  ________
4-digit code for AMEX on card front over card number to extreme right _______
Card owner's name as it appears on the credit card __________________________________________
I authorize KohlQuest, acting for Hoophole, to charge the above credit card account for the amount of registration fees indicated on this registration form. [Your signature must appear in order to pay your registration fee by credit card.] _________________________________________________________________________________

Write the name of the courses, classes, workshops, or retreats you wish to attend, the dates for each session you have selected, and each course/class fee in the space indicated. Total the fees for each class you have registered to attend. The TOTAL is your final registration fee. If paying by credit card, that total amount is what will be charged to your credit card account.
__________________________________________________ class fee  $___________
__________________________________________________ class fee  $ ____________
__________________________________________________ class fee  $ ____________
__________________________________________________ class fee  $ ____________
__________________________________________________     TOTAL   ___________

Thank you for registering. You will receive a registration confirmation via email or phone if you have no email address. Should you have any questions, do not hesitate to call 828 288 0730 or send an email to: hoophole@kohlquest.com.