For security reasons, the university no longer accepts a submittable registration form.
Internet and email registration will not be accepted.
Please fill out this form, print it, and enroll by fax, mail or phone at the numbers and address below:
Confirmations of enrollment will be sent within a week after the registration
form and fees have been received and processed. For further information call 707/664-2394.
| Name |
last
first
middle initial
|
| Address |
If your child lives in two homes, please supply copies of all information
to their other parent or guardian.
|
| City |
|
| State |
|
| Zip |
|
| Social Security#: |
|
| Age: |
|
| Birth Date: |
|
| Grade Level |
(If applying for summer session, put grade student will be in in the
fall.) |
| Which program are you applying for?: |
Saturday University
EXCEL for Youth |
| Day Phone |
|
| Home Phone |
|
| Email |
|
| Security Flag |
Please type "ssu" in this box (security check to prevent spam) |
| Photos |
It is possibile that a photo of your child may be used on our brochures or web site. No names will be used on any image of a child. If you object, please check box.
|
| Carpool |
CARPOOL: If you don't want your phone number released check box.
|
| Courses
you wish to enroll in: |
|
Refunds:
Provided Extended Education is notified 2 weeks prior to the scheduled
class date:
A $25 nonrefundable processing fee is deducted for each class dropped
(Summer Session);
a $10 nonrefundable processing fee
is deducted for each class dropped (Saturday University).
No refund is given if canceIing within two weeks of first day of
class. |
Emergency and Medical Information
(Must be completed with signature to be officially registered). |
| Please note order of notification: |
| Parent/Guardian Name |
|
| Day Ph# |
|
| Home Ph# |
|
| Parent/Guardian 2 Name |
|
| Day Ph# |
|
| Home Ph# |
|
| Designated adult other than parent: |
|
| Relationship to child: |
|
| Day Phone |
|
| Home Phone |
|
| Name of
child's healh plan |
|
| Membership # |
|
| Family Physician |
|
| Phone # |
|
| Special needs or learning
disabilities? |
Yes
No
If yes, it is required to arrange a meeting with the Excel Coordinator, Alison Marks, either by phone or in
person. |
| Medical problems/physical conditions/ including allergies or special medications? |
Yes
No
If yes, please explain:
(Inhalers, special medicine or bee sting kits must be carried by students
at all times). In the event of a health-related emergency, I authorize
a staff member of Extended Education to take my child either to the
on-campus Health Center or summon other emergency assistance as deemed necessary for the safety
and protection of my child.
|
As a parent or guardian, I agree to be responsible for costs to repair any SSU equipment damaged
by my child, either intentionally or through reckless behavior. I also take responsibility for my child to comply
with the EXCEL guidelines.
I have read and understand the guidelines (spring guidelines | summer guidelines) |
By checking here, I am signing this form. (This check box is in lieu
of a signature if appying online.) |
| FINANCIAL INFORMATION |
| Type of Credit Card |
VISA
MasterCard
Discover Card
AmEx |
| In the amount of $ |
|
| Card Holder
Name |
|
| Card # |
|
| Exp. Date |
|
| Signature (only if mailing or faxing) |
|
| Date |
|
The Disability Resource
Center provides complete access to the University for students with
disabilities.
For information see the General Information section or phone 707/664-2677
(voice) or 664-2958 (TDD).
SSU is an AA/EEO Institution.
|