rooster painting

EXCEL FOR YOUTH REGISTRATION FORM
at Sonoma State University

Parents or guardians must read guidelines for EXCEL before completing this form.

How to Register:

This form is for those registering without a credit card. If you are registering with a credit card, use our online registration form. Please fill out this form, print it, and mail with check to address below. You can also enroll by fax or phone at the numbers and address below

Extended Education
1801 E. Cotati Ave.
Rohnert Park, CA. 94928
tel: (707) 664 2394
fax:(707) 664-2613

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.)
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:
Course Title Class # (0000) Fee
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. 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 (guidelines)

By checking here, I am signing this form. (This check box is in lieu of a signature if appying online.)

Signature
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.