First Name	:
Last Name	:
Age Range	:	Under 14 14 - 18 19 - 25 26 - 32 33 - 39 40+
E-mail Address	:
Phone number	:
Alt. Phone number	:
City	:
Province/State	:
How did you hear about Cordova Academy?	:	A Friend From Family Internet Search E-mail Forward Community Announcements Referral
What factors affect your decision to take a course?	:	Topic Course Fee Instructor Quality Timing
Subject	:
Message	:

Cordova Academy respects your privacy. Any and all information is collected solely for Cordova Academy, it will not be shared with any other party for any reason. The information collected aids us in preparing course materials, assisting to make each class a better experience and in notifying past and present participants of our programs and activities. Please, fill in all sections of the form. To make more than one choice, kindly hold down the CTRL button. We understand that your time is very valuable and appreciate your taking the time to complete this form. Thank you.