Posted: Wednesday, September 01, 2010

FALL 2010

BUILDING BRIDGES REGISTRATION FORM

A five-week small group experience in cultural diversity to include:

Workplace Issues, Religious tolerance, consolidation of the

 Place:  Poynor Adult Center – 301 S. Dargan Street – Room 2A

 Cost:    $15 (five-week session); $10 each for five or more

Registration is limited!  Pre-registration is helpful in our efforts to prepare for each session.  You can earn 2 CEU credits from FDTC (Must attend at least 4 of the five sessions).  First and last sessions are mandatory.   Please return this form with your payment.  For more information, call the Chamber at 843.665.0515.

(Please Print)

Name: ______________________________________________________________

City: _______________________ State: _______  Zip Code: ___________

Daytime Phone:  _________________________  Fax: _________________

Email: _______________________________________________________________

To ensure diversity in the composition of small groups, please complete the following:

Gender:       [] Male           [] Female                  Race: __________________

                                                                                                                                                                                       (Optional)

Age Group:     [] Under 34        [] 35-49         [] 50-64         [] 65

Religious affiliation, if any: _________________________________________________________

                                                                                                                                            (Optional)

Occupation: _________________________________________________________

Fee Schedule

Building Bridges Seminar - $15                                                                           $__________

Group of 5 ($10 each)                                                                                            $__________

[] Visa            [] MasterCard               [] American Express      []Discover

Credit Card #: _______________________________________________________________

Expiration Date: __________  Verification Code (on back of card) ________

Print Name: ______________________________________________________________

Authorized Signature: ___________________________ Date: ____________

Mail this form along with payment to:

Building Bridges

Greater Florence Chamber of Commerce

POB 948, Florence SC  29503-0948

Phone: 843.665.0515      Fax: 843.662-2010