SID:
Quarter:
Senior Citizen Registration Form
(Tuition Waiver Classes)
First Name: Last Name: DOB
Address: Apt#
City: State: ZIP: Phone
I wish to register for the following classes. Registration is for either credit or
audit only, and is on a space available basis. There is a $5.00 non-refundable
fee
per quarter plus other applicable college fees. This tuition waiver is limited
to two classes per quarter.
Item Number Course Title Room Time Day
Audit Credit
Audit Credit
Attend the first day of class and inform the instructor that you are a senior and wish to en-
roll in the class, either for credit or audit.
If there is space available in the class on the 6th day of the quarter (4th day summer quar-
ter), have the instructor sign this form and bring it to the registration office in the FOSS
(5200) building, along with your payment.
The $5.00 fee does not include college fees and class fees. You will be required to pay any
and all special fees.
I hereby certify that I am at least 60 years of age, and that certification of false information may
lead to civil or criminal charges.
Student Signature Date
Instructor Signature Date
Instructor Signature Date
Item Number Course Title Room Time Day
