Registration by Proxy Form
Name of Student to be registered: _________________________________________________
Social Security Number: __________________________________________________________
Name of Authorized Party: ________________________________________________________
I hereby grant approval for the person named above to serve as my authorized proxy for the
purpose of registration at Clovis Community College. This person may have access to any and
all of my records needed to register on my behalf, including selection of courses, correction of
addresses and telephone numbers, signing documents for me, and payment of my tuition and
fees in my absence.
_____________________________________ ________________________
Signature of Student to be registered Date
_____________________________________ ________________________
Signature of Proxy Date
**Please return completed form to Admissions**
