Print out, complete, and mail, with payment (if applicable) to address below:

Please register the following individual(s) for:

Workshop Name: _______________________________________________________

Workshop Date(s): ______________________________________________________

Workshop Times: _______________________________________________________

Workshop Cost: ________________________________________________________

Name: ______________________________________ Phone: ___________________

Email: ____________________________________________________________

Address: __________________________________________________________

City: _____________________________________ State/ZIP: _________________

How did you hear about MERCY? _______________________________________

____ Check is enclosed, payable to MERCY.

Mail completed form, with payment (if applicable), to:

David and Penny Hudson

MERCY

c/o 505 Wood Springs Road

La Grange, KY 40031