REGISTRATION FORM / FORMULARIO DE INSCRIPCIÓN

Personal Information:

First name/Nombre: ________________________________________________________      

Last name/Apellido: ________________________________________________________ 

School Board/Consejo Escolar:  _______________________________________________

Home address/Direccion personal:

Street/Calle: _____________________________________________________________

City/Ciudad: _________________________________         Province/Provincia: ________  

Postal Code/Codigo Postal:  _____________________

Phone/Telefono:

Home/De casa:  _____________________   Work/De trabajo: _____________________

E-mail/Correo electronico:  _______________________________________________

Are you a member of APH-C/ Es Ud. miembro de la APH-C

□ Yes/Si                                                           □   No/No

Do you want to become a member/ Desearia afiliarse:

□ Yes/Si                                                           □   No/No