Registration FormEnvironmental Health and Safety Training
We must have a five-day advance notice prior to the class. Course fees may be billed to an employer, charged to MasterCard or Visa, or paid by check. TO BILL TO A CREDIT CARD, PLEASE CALL MARSHA WILLOX AT 1-800-464-6874 WITH THE CARD NUMBER AND EXPIRATION DATE. You will not be registered for the class until this information has been provided. NOTE: If you cannot attend, please call and withdraw from the class or you will be billed.
* Denotes required fields.
* Course Title
* Section or Course Number
* Date of Course
* Name
* Social Security Number
* Daytime Phone Number
* Address
* City
* State/Zip
* Employer
* Mailing Address
* Method of Payment
NOTE: If paying by check, mail it to Kirkwood Community College, Attn: Marsha Willox. If paying by credit card, you must call Marsha Willox at 1-800-464-6874 with the card number and expiration date before you can be registered for the class.