GROSSMONT ADULT EDUCATION
Registration for On-Line Classes (ONLY)
Mail or FAX this completed form to:
Santana Adult Center, 9915 N. Magnolia, Santee, CA 92071
FAX (619) 562-5149
If using a credit card, your signature is required (one form per person)


For your security, after typing in the registration information and printing this form,
click the "Clear Information" button above to remove your personal information.

Last Name
First Name
Middle Initial
Gender
Male     Female
Birthdate
/ /
Street Address
Apt. Nbr.
City
Zip Code
E-mail Address
Home Phone
( ) -
Work Phone
( ) -  Extension
 
LIST THE COURSES YOU WANT TO TAKE
Course #
Course Title
         Fee
1
$
2
$
3
$
Total Enclosed:
$

PLEASE ENCLOSE PAYMENT WITH YOUR REGISTRATION

If registering by fax, you must pay by credit card (must include V-Code on back of card). If using US Mail, you may pay by check or credit card. DO NOT MAIL CASH.
Your signature is required regardless of payment method and signifies you have read the Liability Waiver.
Payment:
Cash    Check (enclosed)    Visa    Master Card
Card # Expires (mo/yr) / V-Code 3#s

Liability Waiver: By signing below, the student agrees that neither Grossmont Adult School nor it's employees shall be liable for any and all injuries, loss, and other damages that may be suffered by reason of voluntary participation in class activities. No refunds unless class is canceled by administration.Your signature is required below and must be original. Thank You.
Your Signature:    
Date: