PROFESSIONAL DEVELOPMENT
REGISTRATION FORM
127 W. Bruce St, 3
rd
Floor, MSC 6906, Harrisonburg, VA 22807 | 540/568.4253 | PCE@jmu.edu | jmu.edu/pce
James Madison University is an equal opportunity/affirmative action institution.
If you require special accommodations, please contact us no
later than 10 business days prior to the program start date.
CONTACT INFORMATION
Name ____________________________________________________________________________________________
First Name Last Name Preferred Name
Mailing Address ____________________________________________________________________________________
Street Apt No. City State Zip
Telephone ________________________________________ Email ________________________________________
Cell Day
Company Name ______________________________
COURSE INFORMATION
Fill-in discount code here, if applicable ________________________
Total Due
(minus any discounts)
PRIVACY AND NOTIFICATIONS
Student Privacy: By registering with JMU Professional & Continuing Education, you consent to the internal, non-public
disclosure of your address, telephone number and email addresses to faculty and staff of JMU including any official third
parties we work with for the purposes of administering the program. This includes facilitating class communications. You
provide this consent with the knowledge that JMU will not further disclose your contact information to anyone outside of
JMU and official third parties without your consent.
You may choose to opt-out of receiving promotional information from our office by checking the appropriate boxes below. *Note: You will still
receive class communications: ___ Do not email me ___ Do not mail me
Media Release: I hereby agree to give JAMES MADISON UNIVERSITY, their assigns and legal representatives the
irrevocable right to use photograph or video images of me in all forms and media for education or other lawful
purposes in its publications and displays.
By proceeding with the registration process, you verify that you meet the requirements to register in the program.
_________________________________________ _____________________________________
Signature of Registrant Date
Mail or drop off the completed form with payment to:
JMU Professional & Continuing Education
127 W. Bruce St, MSC 6906
Harrisonburg, VA 22807
Check should be made payable to James Madison University. A $50 fee will be assessed for any check returned by the bank. Note: Credit
card payment (Visa, MasterCard, Discover, & American Express) can only be accepted through online registration.
Questions about using other funding sources such as private loans, employer payment requiring invoice, Americorps,
MyCAA, etc? Contact us at 540/568.4253 or cpdtraining@jmu.edu.
