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: |
|
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.
|