ADULT ENRICHMENT REGISTRATION FORM
Name: _________________________________________________________________ Home Phone: _______________________
Work Phone: ______________________ Cell Phone: ________________________________ Street Address: _____________________________ City, State, Zip Code: _________________________
Email Address: ______________________________ Emergency Contact: _________________________
By providing your email, you will receive course confirmations, reminders, updates, and cancellation notices. Your information will not be shared outside of the ISD 622 Community Education program.
Emergency Contact Phone: ____________________
Class # Participant Name( First & Last) Class Name Cost
� CHECK( Payable to " District 622 ") Will be handled as a one-time electronic fund transfer or draft
Subtotal Total Cost
� VISA � MASTERCARD � AMERICAN EXPRESS � DISCOVER
Credit Card Number: _ _ _ _- _ _ _ _- _ _ _ _- _ _ _ _ CVV _ _ _ _
Amount: _______________
Expiration Date: _____/____
Signature: ____________________________________ Date: _________________
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