Registration Form

COMMUNITY EDUCATION FALL 2005

*Class size is limited to the first 10 prepaid students.

Social Security Number:

Name:
Last First MI

Mailing Address:

Street, State Route, PO Box

City

State

Zip County

Course date for RSS:

Amount Enclosed:

Basic Riders Course (BRC)
$125.00 in-state
$150.00 out-of-state

Experienced Riders Course
$70.00 plus $25.00 with rider or
$90.00 plus $25.00 Out-of-State

Sex : Male Female

Date of Birth:

Check here if participant is under 18 years of age:

Home Phone:

Work Phone:

Employer: (Optional)

MAIL REGISTRATION FORM AND PAYMENT TO:

Astarre Gudino
West Kentucky Community & Technical College
P. O. Box 7380
Paducah, KY 42002-7380
Phone: (270) 534-3338

ALL CHECKS NEED TO BE MADE PAYABLE TO:
West Kentucky Community & Technical College OR WKCTC

If a class that you are registered for needs to be cancelled for any reason, Carolyn Higgins will notify you prior to the date of the class (within 2 ­ 5 days from the scheduled class date) the student will receive a full refund.

To enroll for a class the student's REGISTRATION FORM & TUITION PAYMENT must be to be to Carolyn Higgins no less than 7 days PRIOR to the class date that you are wanting to attend.