Chesapeake College
Division of Continuing Education and Workforce Training - 410-827-5850
Open Enrollment Registration Form
(All information must be completed to process registration.)
Name:
(Print)
Last First Middle
Home Address:
Street P.O. Box
City or Town State Zip Code
Home Phone #: Work Phone #:
Cell Phone #: E-mail Address:
*Social Security #: *Date of Birth:
(month/day/year)
(Date of Birth is required by the College to ensure the integrity of student records and to meet federal government reporting requirements.) **Online
Registration is now available for non-credit students. A student’s Date of Birth AND Social Security number will have to be on file to be able to
Register online. Include both your Date of Birth and Social Security number on this registration form to be able to take advantage of ONLINE
Registration in the future.
Have you previously been a student at Chesapeake College (credit or non credit): Yes No
Senior Citizen:
(60 or older)
Yes No Gender: Male Female
Ethnicity: Part 1: Hispanic or Latino origin
Yes (HIS) No (NHIS).
Part 2: If you are not Hispanic or Latino, please select one or more of the following:
Race: American Indian or Alaska Native
(AN)
Asian (AS)
Black or African American
(BL)
Native Hawaiian or other Pacific Islander
(HP)
White
(WH)
I certify
that I am a legal resident of County, MD.
Student’s Signature
Date
Method of Payment:
Check Credit Card Money Order Purchase Order
Sponsorship Billing Deferred Payment Plan
In order to process this registration, payment must accompany the completed registration form. If payment is
made by credit card or debit card, information may be faxed to: 410-827-5852.
MAKE CHECKS PAYABLE TO CHESAPEAKE COLLEGE (Do Not Mail Cash!)
Charge my tuition to: (Check One)
VISA
Master Card
American Express
Discover Card
Card Number: Expiration Date: CID#
*Note: CID# is the last three digits in the signature box on the back of your credit card.
Cardholder’s Name:
Authorized Cardholder’s Signature:
NO WRITTEN CONFIRMATION OF REGISTRATION WILL BE MAILED.
You should attend your selected class at
the time listed in the schedule of classes. For more information, call the Division of Continuing Education at 410-827-5850.
COMPLETE COURSE INFORMATION BELOW:
Dept./Number Section
Title & Start Date Tuition Fees Total
$5 Reg. fee per course __________________
Total Amount Due __________________
Note: Caroline, Dorchester, Kent, Queen Anne’s and Talbot county residents are in Chesapeake College’s service area.
Refer to the schedule of classes for appropriate fees. Senior Citizens must pay CES, AFCand FTW, tuition and fees.
Mail registration form with payment to: Chesapeake College, Business Office, P.O. Box 8, Wye Mils, MD 21679.
An E.O. Institution Tobacco-free Campus.
02/16
