College of the Redwoods
Community Education
525 D Street Eureka, CA 95501
707-476-4500 Fax 707-443-3417
Office Use Only
ID # ____________________________
Initials __________________________
Date ____________________________
Receipt # ________________________
Full Legal Name:
Last First Middle
Are you currently, or have you previously, taken classes at College of the Redwoods? □ Yes □ No
Alternate Names Used:
Birth Name Married Name Other
Mailing Address:
Phone Number(s):
Email: Email Newsletter □ Yes □ No
How did you hear about this class?
Date of Birth (required)
SSN (required if you’re a new student)
Student ID
Section #
Course Title
Is your employer paying for this class? □ Yes □ No
Name of Employer: ____________________________________________________________________________________
Company Contact: _______________________________________ Company Phone: _______________________________
Company Mailing Address: ______________________________________________________________________________
Visa/MasterCard/Discover: ___________________________________________________ Exp. Date: __________
Name As It Appears on Card: _____________________________________________________________________
By registering for a CR Community Education class you agree to the registration policies.
Policies can be viewed at
□ Cash
□ Check
□ Credit Card
□ Money Order
□ Sponsorship
Sponsor: _________________________
Phone: _____________________
Sponsor Email: ________________________________________________________________________________________
Office Use Only
Book/Packet Mailed On: ________ Student Pick up Picked Up On ________ Certificate Mail Pick up