Monday - 4pm Group BASICS for 1-9 and 1-23-12

Please Note:

You will not be registered until you complete the payment process AFTER you submit this form
You must attend both days as scheduled to successfully complete the program.
Payment in full is required to reserve your place and is non-refundable.
If paying in cash, please pay $78 exact amount - change is not provided

Class Location:

Connections Counseling

5005 University Ave.

Madison, WI 53705

$78.00

Monday, January 9, 2012 - 4:00pm - 5:30pm

Monday, January 23, 2012 - 4:00pm - 5:30pm

Quantity: *

Personal Information

First Name: *

Middle Initial: *

Last Name: *

Date of Birth: *

Gender: *

Email Address: *

Student Information

Student ID #: *

Year in School: *

Completion Deadline Date:

Referral Information

Referral Source: *

UW-Madison Dean of Student’s Office

UW-Madison Housing

Madison Police Department

University of Wisconsin Police Department

Referral Name:

The name of the person who referred you to BASICS

AFTER submitting this form, you will not be registered until you complete the checkout process on the next page

Group BASICS Classes