Class Registration

*Name of Class:

Date(s) of Class:

*Name:

Address:

City/Zip:

*Phone (Home): Phone(Work):

Email:

THIS IS A SECURE TRANSACTION*.

Fee Enclosed:
Payment Type: VISA MC Will Mail Payment
Card Account# *3 digit Security Code
Expiration:   Month  Year 
Name of Cardholder, as it appears on the Card:


If you prefer to pay by mail, please print this
registration form and send it with your payment to:

Educational Services
Marshall Medical Center
1100 Marshall Way
Placerville, CA 95667

No refunds unless notified within 48 hours of class. Refund reflects $10.00 material/processing fee.  Full refund if canceled by Marshall Hospital.

*This form uses Verisign SSL secure encryption. You may
verify this by making sure you have the CLOSED padlock icon
showing at the bottom of your browser window. You may click
on the Verisign icon at the top of the form to verify
Marshall's registration with Verisign.