EXCEL for Youth Registration Form (mail or fax only)

DO NOT EMAIL THIS FORM - IT WILL NOT BE ACCEPTED OR PROCESSED.

Fill in, print, then mail or fax to: SSU Extended Education, 1801 E. Cotati Ave., Rohnert Park, CA. 94928

   
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, and mail or deliver a check in person.
Extended Education 1801 E. Cotati Ave. Rohnert Park, CA. 94928 tel: (707) 664-2394 fax: (707) 664-2613
 
 


 Course Title
 Class #
 Fee

REFUNDS:
Provided Extended Education is notified 2 wees prior to the scheduled class date, a $25 nonrefundable processing fee is deducted for each class dropped. No refund is given if canceling 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:



(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.

In the event of a health-related emergency, I authorize a staff member of Extended Education to take my child either to the above named physicin, the on-campus Health Center, or the nearest Emergency Hospital for treatment and emergency measures deemed necessary for the safety and protection of my child. As a parent, 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.

The Disability Resource Center proides complete access to the University for students with disabilities. For information , phone 707/664-2677 (voice) or 664-2958 (TDD). SSu is an AA/EEO Institution.
*I have read the EXCEL Summer Guidelines:
Pick a date




Print this form, then write signature where required. If faxing, you may fax the printed form. Fax number: (707) 664-2613. If mailing, without using credit card, please attach check or money order to this printed form, and mail to:

SSU Extended Education 1801 E. Cotati Ave. Rohnert Park, CA. 94928.