INSTRUCTIONS: You may use this form to register in person, by mail, or by FAX. If registering by
mail, return this form to the address below. If registering by FAX, dial (269) 565-2129 in Battle Creek,
(269) 948-9522 in Hastings, (517) 278-3311 in Coldwater, or (517) 630-8169 in Albion. Payment for
tuition is due by charge card if registering by FAX—do not send cash. To make payment, complete the
information and authorization on the bottom of this form. This form must be received and processed
prior to the rst class meeting. Incomplete forms, forms received after the rst class meeting, and forms
from students who have outstanding accounts will not be processed.
1 Please print the following information.
NAME Last First MI
ADDRESS Street Number/Name
CITY STATE ZIP CODE DATE OF BIRTH
HOME PHONE NUMBER
Lifelong Learning Member Would like to become LLL Member (Please include $25 Member Fee)
YES NO YES NO
2 Enter your course selections
SUBJECT AREA COURSE NUMBER SECTION NUMBER
The information on this form has been provided by me and is true and complete to the best of my knowledge.
I agree to provide proof of any information if it is requested. I understand that false/or misleading information
may lead to loss of course credit, loss of tuition and fees paid, dismissal from KCC, and/or criminal action.
Student’s Signature ________________________________________________________ Date ______________
CREDIT CARD INFORMATION/AUTHORIZATION
If you wish to charge your course fees, please complete the following information:
$ Please Specify Card Type:______________________________________________________________________________________
Amount you wish to charge
Expiration Date _____________ ____Cardholder’s Name__________________________________________________________________
Cardholder’s Signature _______________________________________________________________
Kellogg Community College
450 North Avenue
Battle Creek, MI 49017-3397
LIFELONG LEARNING REGISTRATION