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: _________________________
Iagreetopraccesocialdistancing,whenpossible,andwearafacemaskorshieldwhileinECCfacilies.
Wheredidyouhearaboutthisclass?__________________________________________________________________
RegistraonForm
FOR OFFICE USE ONLY
RegistraonDate:
_________________________
Registeredby:
_________________________
Invoice #: Roster:
____________ _________
Payments Applied in QB/Roster:
_________________________
Semester Class Name Day/Time Locaon Fee
$
$
$
$
Total: $
Fees are due at the me of registraon to secure your place in class.
Refund/Withdrawal Policy
Occasionally,classesmayberescheduled,consolidatedorcanceledatthediscreonofEastCentralCollegeCommunityEducaon.IntheeventofaclasscancelaonbyEastCentralCollegeCommunity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thestartoftheclass.Studentsthatwithdrawlessthan48hourspriortothestartofclassshallforfeittheirrighttoarefund.Allregistraonsincludea$5.00
nonrefundableregistrationfee.Someprogramsmayhavespecificpolicieswhichwillbenotedinindividualclassdescriptions.Locations,datesandtimesaresubjecttochange,butparticipantswillbenotified.EastCentralCollegedoesnotdiscriminateonthebasis
ofrace,color,religion,nationalorigin,ancestry,gender,sexualorientation,age,disability,geneticinformationorveteranstatus.Inquiries/concernsregardingcivilrightscomplianceasitrelatestostudentprogramsandservicesmaybedirectedtoVicePresident
ofStudentDevelopment,131BuescherHall,1964PrairieDellRoad,Union,MO63084,(636)584-6565orstnotice@eastcentral.edu.
Email/Mail to:
East Central CollegeAn:CommunityEducaon
1964PrairieDellRoad•Union,MO63084
ce@eastcentral.edu
By Phone:
Phone:636.649.5803
In Person:
East Central College
Business & Industry Center
42PrairieDellPlazaDrive•Union,MO63084
Registraonpaidbycheck
(makepayabletoEastCentralCollege)
Check#:____________________________________
Registraonpaidbycash
(onlyacceptedattheCommunityEducaonoceinUnion)
Amount:$___________ReceivedBy:____________
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RegistraonForm FOR OFFICE USE ONLY (East Central College)

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Completed 3 February 2021

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