FALL 2011/WINTER 2012


Last Name First Name


Birthdate Female Email Address City Home Phone Number Fall Course # Work Phone Number Title Street Zip Code Extension Fee Male


ESCONDIDO ADULT SCHOOL REGISTRATION FORM Please Print


Middle Ethnic Group


Asian Black


Hispanic


Pacific Islander White


Middle Eastern Other


Winter Course #


Title


Fee


Total $


No cancellations are accepted after the class begins even if you have not attended. There will be absolutely no refunds after the first class meeting.


Please enclose payment with your registration. If registering by fax, 760-747-2017, 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 Cash


Check (enclosed) Visa


MasterCard Amex


Credit Card #: Expiration (Mo/Yr) /


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 CONFIRMATION NOTICE WILL BE SENT 5


REGISTRATION FORM


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