Registration Form Last Name


Daytime telephone (include area code) First Name Address—Number and Street City Email State Zip Code Enter here any other name which you have used at CSUSM M.I.


Date


I am registering for the following courses: Course Number


Course Title


Fee


Membership Fee ❏ $35 General ❏ $295 Annual ($525 Couple) TOTAL


FRIENDSOF OLLI


We are a non-profit organization dedicated to spreading the "joy of learning" throughout the area. Become a Friend of OLLI today!


I would like to become a "Friend of OLLI" by donating $ _____________. ❏ Please charge my credit card. ❏ Enclosed is a separate check payable to CSUSM (tax id # 80-0390564).


How did you first hear about the program/course? (Check one option only)


❏ Osher Lifelong Learning Institute Catalog


❏ Friend/Relative ❏ Instructor


❏ News Story in Paper/TV


❏ Email


❏ Search Engine (like Google)


❏ Internet (EL Website) ❏ Direct Mail ❏ Advertisement ❏ Other


________________


By submitting this registration form to CSUSM Extended Learning, you agree that you have read and understood the refund policy for OLLI courses stated below and agree to the stated deadlines and policies. Refund Policy: Once registration is processed, written notice must be made three days prior to class start date in order to receive a full refund (less a $20 administrative fee). Written notice may be made by e-mail to el@csusm.edu or fax to 760-750-3138, or mailed with the postmark date three days prior to the first day of class. If the class is cancelled due to low enrollment, a full refund will be processed.


Signature:_____________________________________________________________________ Date:_______________________


IMPORTANT Make checks payable to CSUSM. Payment by: ❏ Cash


❏ Check or Money Order ❏ Master Card ❏ Visa


❏ Discover


❏ American Express


Credit Card Number:_________________________________________________________Exp. Date:__________________Security Code:______________ Print Cardholder’s Name:___________________________________________ Cardholder’s Signature:____________________________________________


Mail to: CSUSM Extended Learning 333 S. Twin Oaks Valley Road San Marcos, CA 92096


Phone: (760) 750-4020 (800) 500-9377


# (PLEASE PRINT CLEARLY)


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