The Wood River Valley Chapter of the Idaho Master Naturalist Program DATES: January 11th —April 9th, 2011 REGISTRATION INFORMATION Name ____________________________________ email ______________________ Mailing Address _____________________________ City ______________________________________ ST _____ Zip _____________ Phone (Home) __________________
(Cell) _____________________
PAYMENT INFORMATION (COST is $195*) Circle Payment type:
Check enclosed
Credit Card:
Visa
or
Mastercard
Name on card ___________________________ Billing Zip Code ___________ Card number ______________________ Exp. Date _______ Security Code _______** ** The last three digits of the number on the back of the card Signature ______________________________ I am able to give $_____ extra to help support a scholarship for another participants. (Refunded if not distributed)
*Upon certification (40 hours basic training, 8 hours advanced, and 40 hours service) you will receive a $50 refund TO REGISTER: Send this form to the ERC, P.O. Box 819, Ketchum, Idaho 83340 with your check (or credit card information) by December 22nd, 2010. Questions? Lisa Huttinger, ERC, 726-4333; Keri York, Wood River Land Trust, 788-3947
Sawtooth NRA