Office of Educational Outreach

LEISURE LEARNING ACTIVITIES
REGISTRATION FORM

Please complete in full:

Term: ____________________________________________________

Name:____________________________________________________

SS#:_________________________ E-mail:_______________________

Address:__________________________________________________

 Day Phone:__________________ Evening Phone:________________

_____ Yes, I need a Special Parking Permit.
Required only for activities Mon. - Fri.

Vehicle Info: Make: ______________ Plate : __________State: ______

(Please include $10 for the Special Parking Permit.)
Parking tag must be paid for at least TWO WEEKS PRIOR to the event.

SIUE Affiliation? ____Current Student ____Alumni ____Employee ____Retiree ____None
(Check all that apply)

Please register me for the following Leisure Learning/Career & Professional Development Activities.

Class:________________________ Section:_________ Fee:_________

Class: ________________________ Section: _________Fee:_________

Cash_______ Check_______ Visa/Master/DiscoverCard____________

Acct#:_______________________________Exp. Date:_____________

Card Code (last three digits on back of card):_______________________

Billing Address:_____________________________________________

__________________________________________________________

Signature: __________________________________________________

please make checks payable to SIUE.  Send form with payment to:
Office of Educational Outreach,
Box 1084, SIUE,
Edwardsville, IL 62026-1084.