EVENT REGISTRATION FORM
Course Name Course Date
Primary Attendee
Name: WCA Member Y / N Initial Certification Y / N
Clinic Name: DC Name (for staff)
City / State / Zip:
Additional Attendees Please note: a unique email address for each person is required for online course registration.
Attendee #2 Name Email
Attendee #3 Name Email
Attendee #4 Name Email
Payment Required at the Time of Registration Please use the card below for WCA membership dues
Credit Card: VISA / MATERCARD / DISCOVER / AMEX Check # (mailed registrations only)
Name on card:
Billing Address on card: Card Number:
Billing City / State / Zip:
20% Early Bird Discount when you register 20 days before the event (except for Convention, which is 30 days before)
Cancellations incur a $20 admin fee. No cancellations or refunds less than 48 hours prior to the start of the event (except for Convention, which is 7 days). Email registration@wichiro.org to request a refund.
You may register onsite as long as there is room - check the website for last minutes changes and to see if the course is full
Online: wichiro.org/events
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