Department of Extended Learning
Class Registration Form
Your Name
(Required)
:
First:
M.I.:
Last:
Date of Birth
(Required)
:
Address
(Required)
:
Street Address:
City:
State:
Zip Code:
Telephone
(Required)
:
Day:
Evening:
Email Address:
Item #
Course ID
Class Dates
Class Name/Title
Cost
Total Due
REQUIRED: Please answer the following questions:
1) Are you:
A citizen?
Yes
| No
2) Your Gender:
Male
| Female
Disabled?
Yes
| No
A Veteran?
Yes
| No
Type in KeyCode
KeyCode:
You will be called for your credit card number. (We accept
Visa, MasterCard, or Discover Card
)
Submit Electronically: