Community Education Enrollment Print-Out Form
MAIL TO: Napa Valle College, Upper Valley Campus, 1088 College Avenue, St. Helena, CA 94574, Fax: (707) 967-2909
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Social Security # ________ - ________ - ________
Fall Spring Summer 20____
Name: ___________________________ ____________________ _____
(Last) (First) (In.) (Other name used)
Address: _____________________________City: _____________
State: ____ Zip Code: _____
Phone (––––) ____ - _______ Date of Birth: ____ - ____ - _____
Male Female
U.S. Citizen: Yes No
| If registering for on-line classes, please list your e-mail address here: ________________________ |
| Support Services for the Disabled: Please call (707)253-3080 to inquire about support services for the disabled. (TDD: 253-3085) |
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Registration No. |
Course Name |
Instructor |
Start Date |
Time |
Room |
Fees (if any) |
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TOTAL FEES: |
| A separate check for each class registration facilitates prompt return in case of cancellation. Please be aware of our refund policy before enrolling. |
| To pay by credit card, complete the following: Check one: VISA MasterCard Card No.:____________________________ Expiration Date: ______________ Card Holder: _________________________ Signature: _________________________ Date: _________________________ |