Name______________________________

M/F__________ Date of Birth___________

Address_____________________________

City________________________________

State______________ Zip______________

Phone (home)__________ (work)_________

Person to be Notified in Case of an Emergency:

Name_______________________________

Relationship___________________________

Phone_______________________________

Session Desired                            Session Date

____________________________________

STATEMENT OF UNDERSTANDING:

I hereby certify that the above information is correct and that I have read and 
fully understand all course requirements including prerequisites, attendance, refund 
policy, and authorization, as described in this site.

_______________________________

Signature of Applicant

______________________________

Signature of Parent/Guardian (if under 18 year)

AMOUNT ENCLOSED_______________

Please Print & Mail to:

Matagorda County Chapter
American Red Cross
2417 Avenue G
Bay City, TX 77414

For Further Information Please call (979) 245-3056