Community EduCation - Nicolet College

Community Education Registration FormPLEASE PRINT. ALL REQUESTED INFORMATION IS REQUIRED FOR ENROLLMENT.Office Use Only______________________________________________ ____ ______________________________________________ ______________________________________________First Name MI Last Name Social Security # or Nicolet Student ID #______________________________________________ _____________________________________________________ _________ __________________________________Home Mailing Address City State Zip___________________________ ___________________________ _____________________________ ___________________________ ________ / ________/ ________Phone: Home Phone: Cell Work County of Residence Municipality of Residence Date of Birth(Township/Village/City)Gender: Male Female Email Address ______________________________________________________________________________________________________________THE FOLLOWING INFORMATION IS FOR STATE REPORTING PURPOSES. INFORMATION PROVIDED WILL NOT INFLUENCE COURSE ADMISSION.Ethnicity: Are you Hispanic or Latino (regardless of race)? Yes NoRace: (Check all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander WhiteHighest Educational Grade Completed: ______________________ Year of High School Graduation/GED/HSED: _____________________________What is the highest level of credential you have earned? No Credential GED HSED HS Diploma Some College Short Term Diploma 1-Year Diploma2-Year Diploma Associate Degree Associate Degree + Additional Credential Baccalaureate More than BaccalaureateClass Title Class Number Dates Day(s) Time Location Fee/Sr. Fee*FEES ARE DUE WITH REGISTRATION*Senior Fees for people age 62+ are available for Continuing Education classes only TOTAL FEES:MAIL TO:Nicolet CollegeAttn: CE RegistrationPO Box 518Rhinelander, WI 54501PAYMENT METHOD: Check/Money Order (Payable to Nicolet College) MasterCard Visa DiscoverCard Account Number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___Expiration Date: ___ ___/___ ___/___ ___Verification Code: ___ ___ ___ ___ - ___ ___ ___ (from signature line on back of credit card)FOR MORECardholder Signature: _________________________________________________________INFORMATION:Rhinelander: 715.365.4493 or 800.544.3039, ext 4493 • Minocqua: 715.356.6753 or 800.585.9304If participant is under age 18, please sign below. Must be signed byparent or legal guardian.I give my permission for my son/daughter to enroll in the aboveclass(es) at Nicolet College________________________________ _______________Signature DateRevised 10/12Fill out form, cut out and mail in an envelope to: Nicolet College,ATTN: CE Registration, PO Box 518, Rhinelander, WI 54501