REGISTRATION FORM
Section No.
CES, CES2,
CESN No. Title of Class Amount
$
.
$
.
$
.
$
.
$
.
$
.
$
.
TOTAL:
$
.
Registration/Admission Form
Please use one registration form per student. Duplicate this form as needed.
This form will be used to update your contact information.
For name change requests, contact the Registration Ofce/Answer Center
at 734-462-4426.
- -
OR
- -
DATE OF BIRTH (MM-DD-YY)
STUDENT NUMBER SOCIAL SECURITY NUMBER
LAST NAME FIRST NAME MI/FORMER NAME
NUMBER AND STREET CITY
STATE ZIP CODE EMAIL ADDRESS
- - - - - -
DAY PHONE EVENING PHONE CELL PHONE
Enclosed is my Check/Money Order payable to Schoolcraft College (if your check is returned because of insufcient funds, we may redeposit it electronically)
Charge to VISA/MC/Discover/AMEX No. _________________________________________________ Exp. Date _____/_____
Signature required for charge card payment
Company-paid tuition:
Please send a copy of your purchase order when you register.
Co. Name ________________________________________
Co. Address ______________________________________
Billing Contact Person _____________________________
PO# _____________________________________________
For ofce use only:
Mail to:
Schoolcraft College
Registration: CEPD
18600 Haggerty Road
Livonia, MI 48152-2696
To be assigned to rst-time students.
AND
Continuing Education
Professional Development
Schoolcraft College
Returning students only need to include the last 4 digits.
❍ Male ❍ Female
1.
Are you Hispanic?
Yes
No
2.
Please select one or more races:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacic Islander
White
If registering for a Physical Fitness class, review waiver online at www.schoolcraft.edu/cepd/registration
before registering. Your registration signies agreement to the waiver terms.
