601 East College Drive
Winnebago, Nebraska 68071
Phone: (402) 878-3302
Fax: (402) 878-2355
COMMUNITY EDUCATION REGISTRATION FORM
Please answer all questions on this form and send it together with you payment to:
Little Priest Tribal College P.O. Box 270 Winnebago, NE 68071.
Make checks payable to Little Priest Tribal College. You must be 18 or older to register.
NAME: _______________________________________________ E-mail: ________________________
Last First Middle
Street/P.O. Box City State Zip
HOME PHONE: ________________________ BIRTHDATE: ______________________
Are you a U.S. Citizen? ( ) Yes ( ) No SEX: ( ) Male ( ) Female
ETHNICITY: ( ) American Indian/Native Alaska Tribal Affiliation: ________________
Enrollment No. _______ Agency: ____________________________
( ) White/Non-Hispanic ( ) Black/Non-Hispanic ( ) Asian/Pacific Islander ( ) Hispanic
PERMISSION TO USE PHOTOGRAPHS/VIDEOS:
Please check one below
( ) I grant OR ( ) I do not grant permission for Little Priest Tribal College and it representatives the right to take
photographs of me, my property, or child in connection with the above-identified workshop. I authorize LPTC, its assigns
and transferees to copyright, use, and publish the same in print and/or electronically, for a period of one year. I understand
that I will not be compensated for the photos or time spent while taking photos. I also acknowledge that there will be no
notice given to me as to when or how LPTC or its designees may use the photos.
*Carefully read the important statement below before signing.
I certify that the above information is correct. I understand that I am responsible for any changes incurred as a result of my enrollment in this workshop. I
have indicated above how I intend to pay for charges. It is my responsibility to follow through with the necessary paperwork and/or contracts to finalize
payment arrangements. In the event that you need to cancel, payment can only be refunded if notification is received five days prior to the start
date. (American Indian/Native Alaskan participants: My signature also authorizes the BIA or Tribal Enrollment Office to release my tribal certification to
the Little Priest Tribal College Admissions Office.)
Participant/Guardian Signature Date Program Sponsor (if applicable)
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