APPLICANT INFORMATION
Grade
Any food allergies or special needs?
Date of Birth
New Student?
nn
Yes
nn
No
Gender
nn
Male
nn
Female
LIST COURSES:
Excursions in Learning
Youth Programs Registration
CRN COURSE TITLE TIMECOURSE DATES ROOM FEE
TOTAL FEES:
(After Discount)
METHOD OF PAYMENT
Payment Information (please check only one):
nn
American Express
nn
Discover
nn
MasterCard
nn
Visa
nn
Money Order
nn
Check # ____________________________
Cardholder Signature Date Signed
Cardholder Name (print)
Cardholder Address
Credit Card Number
Please indicate method of payment below. Make checks payable to MCC.
Expiration Date
Cardholder Phone
CVV Code
December 2020/PR
Complete this form per person. Refunds according to MCC policy. All friend/sibling discounts must be submitted together. You may register:
ONLINE: Go to www.manchestercc.edu/continuing-education/excursions-in-learning/excursions-in-learning-registration/. After registering online, please call 860-512-2804 to pay
by credit card and disclose child’s birthdate.
BY PHONE: Complete this registration form and phone 860-512-2804 with credit card payment information.
BY EMAIL: Scan completed forms and email to larmstrong@manchestercc.edu.
DISCOUNT: See catalog. (select only one)
n Early Registration
nn
Multiple Sibling or Friend
Name of Sibling or Friend
First Name MI Last Name Banner ID (if known)
Home Address City State Zip
Parent/Guardian Name(s) Email for Registration Confirmation
How did you hear about us?
nn
Email Blast
nn
Newspaper Ad
nn
Friend
nn
Internet Search
nn
Our Child’s School
nn
Town Library
nn
Facebook
nn
From MCC Student
nn
Website Listing____________________________________
nn
Other __________________________________________________________
Home Phone
Best Phone During Class Time
Whose phone is this?
OFFICE USE ONLY
Regis. _________________ Bursar: _________________ Receipt #: ___________________ Date: __________________
Permission to photograph your child and use
photographs for promotional purposes?
nn
Yes
nn
No Parent/Guardian Signature ___________________________________________________________
Age
