registration form & contact info - Merced College Community Services
REGISTRATION FORM & CONTACT INFO 3600 M St. Phone: 209-384-6224 MERCED COLLEGE COMMUNITY SERVICES Merced College Community Services Box 5 Fax: 209-384-6379 Merced, CA 95348 Email: [email protected] Mailing Address: 630 W. 19th Street, Merced, CA 95340 Registration Form tel 209.384.6224 • [email protected] Please use form per person. • www.mHUFHGFRPPXQLW\VHUYLFHVFRP faxone 209.386.6793 Please use one form per person Student Name (Please Print):_________________________________________ Date: __________ Address:__________________________ City: _________________ State: ________ Zip:____________ Phone (home):___________________________ (other): _____________________________ Email: ______________________________________ Session # Activity Title Dates of Activity Visa____ Master Card____ Card Number_________________________ Exp. Date:______ 3-Digit Code______ Signature: __________________________________________ Fee Balance Due Method of Payment: Name of Card Holder: ________________________________ Class Time Want to skip filling out this form? Register online at… www.mercedcommunityservices.com *NOTE: Our registration office is located in the downtown Merced College Business College for Kids Classes, Aquatics, & Sports Camps: Resource Center, 630 West 19th Street. From June 15 to July 30, Student’s Birth Date: _____________ Grade of Student Next Fall: ______ the College For Kids Parent/Guardian Name:_________________ Work Number: _________________ headquarters & registration will be located at Emergency Phone Number: _______________________ Merced College 3600 M Street in Room Art-2. (Cash payments can be completed at the Merced College Business Resource Center ONLY ) I have read and agree to the terms of the cancellation and refund policy online at www.mercedcommunityservices.com. Unless otherwise indicated, I consent to the college's use of any photographs or video that are taken of me or my child while participating in this program for use in publicity materials. I am aware that during any instructional or travel program certain dangers may occur, including but not limited to the hazards of accidents or illness. I hereby release, discharge, absolve and agree to hold harmless and indemnify Merced Community College District, its officers, agents, and employees from any and all liability for injuries, illness, sickness, or disease that may occur while participating in the program. I hereby give my consent for college personnel to authorize any and all emergency medical and dental treatment. Student Signature Parent/Guardian Signature
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