Please mail registrations to
Jan Coffey
P.O. Box 665
Watertown, CT 06795
Name: ____________________________________________________
Address:___________________________________________________
City/State/Zip:_______________________________________________
Home-Phone: _______________________________________________
Cell-Phone:_________________________________________________
Email: _____________________________________________________
Grade: __________________ Age: ______________________________
Please indicate which session you will attend:
__ Session 1: July 18-22, 2011
__ Session 2: July 25-29, 2011
Parental/Guardian Consent:
I give my child permission to attend Step Write Up. I understand there will be no medical personnel/services on-site, and it is my responsibility to alert the staff of any special needs my child may have. I also understand photos of my child may be used for publicity.
Signature: _____________________________
Fee: __ $200
Cancellation Policy:
If you need to cancel your registration for any reason and do so 10 days prior to the start of the session, you will receive credit to attend another institute, valid through summer 2011
Please mail registrations to: Jan Coffey, P.O. Box 665, Watertown, CT 06795
Or copy and send the completed form via e-mail to JanCoffey@JanCoffey.com