es c o n d i d o Ad u l t sc h o o l Re g i s t R A t i o n Fo R m
Last Name
Please Print
First Name Middle
Birthdate
Ethnic Group
/ /
Asian
Pacific Islander
Black
White
Female
Hispanic
Male
Middle Eastern
ORM
Email
Other
F
TION
Address Street
City Zip Code
EGISTRA
R
Home Phone Number
Work Phone Number Extension
Fall Course # Title Fee
Winter Course #
Title Fee
Total $
Please enclose payment with your registration. If registering by fax, 760-739-7310, you must
pay by credit card. If using U.S. mail, you may pay by check or credit card. Do not mail cash.
Your signature is required regardless of payment method. Make checks payable to Escondido
Adult School. There will be a $25 charge for all returned checks.
Payment Method Credit Card #:
Cash
Check (enclosed)
Visa
Expiration (Mo/Yr)
MasterCard
Amex
/
LIABILITY WAIVER: By signing below, the student agrees that neither Escondido Adult School nor
its employees shall be liable for any and all injuries, loss, or other damages that may be suffered by
student by reason of voluntary participation in class activities. 44325
Signature (required) Date
no co n F i R m A t i o n no t i c e Wi l l Be se n t
5
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