REGFORM

SAC CE REGISTRATION FORM (Please type or print neatly) Phone 733-2635
Course Title: ________________________________ Course ID: ____________________

Starting Date: _____________ Ending Date: ____________ Cost: _________________

Course Title: ________________________________ Course ID: ___________________ Starting Date: _____________ Ending Date: _____________ Cost: ________________

Course Title: _________________________________ Course ID: __________________

Starting Date: _____________ Ending Date: _____________ Cost: ________________

Social Security Number: __________ - ___________ - ____________

Name: _________________________________ Phone:___________________________

Address: ________________________________________________________________

City: ______________________________ State: ____________ Zip: _______________

Citizen ___________ State: _________ County: __________ Birth date: _____________

Circle all that apply Marital Status           Sex                                       Ethnicity

S - Single          M - Married
D - Divorced    W - Widower M - Male
F - Female 1 - White (Non Hispanic)               2 - Black (Non Hispanic)
3 - Hispanic                                4 - Asian/Pacific Islander
                    5 - American Indian /Alaskan Native

Residency Issues: What state do you claim as your legal residency? _________________ How long have you continuously resided in Texas ? _______ years _______ months

TO BE SIGNED BY ALL STUDENTS TO CERTIFY THE ACCURACY OF THE INFORMATION PROVIDED:
I certify that the above information is true, complete and accurate, and that I have received information concerning Bacterial Meningitis from San Antonio College.

STUDENT’S SIGNATURE: __________________________ DATE: _____________

You are enrolled in this class unless otherwise notified. Receipts will not be mailed, but will be issued at the first class meeting. Incomplete forms will not be processed. Payment in full (personal checks or money orders only) MUST accompany this form or it will not be processed.

IF CHARGING,ACCOUNT NUMBER: ________ ________ _________ ________ VISA/MASTERCARD

Expiration Date: ____________Cardholder’s Name: ____________________

Student Name: ___________________ Cardholder’s Signature: ______________________

Walk-In: Register in person at the Continuing Education Registration Desk (Room 202) in the Fletcher Administration Center on the SAC Campus.

Registration hours are
8 a.m. - 7 p.m. Monday thru Thursday; Friday 8 a.m. - 5 p.m.

Mail-In:    Complete the registration form include your check, money order or credit card number and send it to:
                                                         San Antonio College
                                                        CE Registration Desk
                                                        1300 San Pedro Ave
                                                        San Antonio, TX 78212-4299

Fax-In: Fax the completed registration form to (210) 733-2054. Be sure to include your Visa or MasterCard Number & expiration date. Please allow time for processing by faxingyour registration atleast two days prior to the class start date.

Refund Policy:
                         100%     Prior to 1st class
                           80%     Prior to 2nd class
                             0%     After 2nd class

Refund requests must be made in person.

Click here for Important Information about Bacterial Meningitis