Workshop Registration Form

Name ___________________________________________

Address _________________________________________

________________________________________________

Phone __________________________________________

Email ___________________________________________

School Affiliation ___________________________________

________________________________________________

Please provide an email address if possible.

Registration deadline is 18 June 2010.

There is a $30.00 registration fee for each participant. Please return registration form with your check payable to:

Historical Society of Cheshire County
c/o Tom Haynes
P.O. Box 803
Keene, NH 03431

Dietary desires for lunch: (check one)
Carnivore _____
Herbivore _____
Omnivore _____
Other needs ___________________________________