Fillable RegistraonForm FOR OFFICE USE ONLY (East Central College)

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RegistraonForm FOR OFFICE USE ONLY (East Central College)

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Name: __________________________________________________________________________________________
(First) (MiddleInial) (Last)
Date of Birth: ______________ Male Female Email: ____________________________________________
Address: ______________________________________ City: __________________ State: ______ Zip: _____________
Primary Phone: ( _______ ) _________________________ Secondary Phone: ( _______ ) _________________________
Emergency Contact: _______________________________________ Phone: ( _______ ) _________________________
Parent Guardian Spouse Other: _________________________
Where did you hear about this class? __________________________________________________________________
RegistraonForm
FOR OFFICE USE ONLY
RegistrationDate:
_________________________
Registered By:
___________________
______
Invoice #: Roster:
______________ __________
Payments Applied in QB/Roster:
_________________________
Semester
Class Name
Day/Time Fee
$
$
$
$
Total: $
Fees are due at the me of registraon to secure your place in class.
Refund/Withdrawal Policy
Occasionally,classesmayberescheduled,consolidatedorcanceledatthediscreonofEastCentralCollegeCommunityEducaon.IntheeventofaclasscancelaonbyEastCentralCollegeCommunityEducaon,eachstudentwillbeprovidedafullrefund.To
withdraw,studentsmustcontactEastCentralCollegeCommunityEducaonnolessthan48hourspriortothestartoftheclass.Studentsthatwithdrawlessthan48hourspriortothestartofclassshallforfeittheirrighttoarefund.Allregistraonsincludea$5.00
nonrefundableregistraonfee.Someprogramsmayhavespecicpolicieswhichwillbenotedinindividualclassdescripons.Locaons,datesandmesaresubjecttochange,butparcipantswillbenoed.EastCentralCollegedoesnotdiscriminateonthebasis
ofrace,color,religion,naonalorigin,ancestry,gender,sexualorientaon,age,disability,genecinformaonorveteranstatus.Inquiries/concernsregardingcivilrightscomplianceasitrelatestostudentprogramsandservicesmaybedirectedtoShelliAllen,Vice
PresidentofStudentDevelopment,131BuescherHall,1964PrairieDellRoad,Union,MO63084,(636)584-6565orstnoce@eastcentral.edu.
Email/Mail to:
East Central CollegeAn:CommunityEducaon
1964PrairieDellRoad•Union,MO63084
ce@eastcentral.edu
By Phone:
Phone:636.649.5803
In Person:
East Central College
Business & Industry Center
42PrairieDellPlazaDrive•Union,MO63084
Registraonpaidbycheck
(makepayabletoEastCentralCollege)
Check#:____________________________________
Registraonpaidbycash
(onlyacceptedattheCommunityEducaonoceinUnion)
Amount:$___________ReceivedBy:____________
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RegistraonForm FOR OFFICE USE ONLY (East Central College)

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Completed 26 July 2020

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