PRE-ENROLLMENT FORM
Name _____________________________ Telephone (h) _______________ (w) _________________
Address ____________________________ City ________________ State _______ (Zip)___________
Email________________________________________Cell Phone______________________________
Highest Degree Earned ______________ Social Security # _______________ DOB_________________
Male ____ Female ____ Race ____ Place of Employment ______________________________________
Send To:
Dr. Charles Jackard
3221 W. 83rd st.
Shawnee Mission, KS 66206
OR
Fax To: 913-648-7039