Registration Form

To register for swimming classes please complete the following:

Student Name:
Please Select Class Time: 9a.m.     10a.m.    7:00p.m.
Please Select Session: Session 1 -June 2 to June 12  Session 2 -June 16  to June 26 Session 3 - July 14 to July 24  Session 4 - Aug. 4 to Aug. 14 (no night classes for this session)
Infant Swimming Classes: July 7-10  July 28-31 Morning Night

CHIPOLA COLLEGE CONTINUING EDUCATION NON-CREDIT REGISTRATION FORM YOU MUST OFFICIALLY DROP A COURSE THE DAY BEFORE IT BEGINS OR YOU WILL BE RESPONSIBLE FOR ALL FEES! $5.00 Late Registration Fee   Please Print

NAME SOCIAL SECURITY# Which of the following options best describes your current situation? I am taking this course to learn skills related to my current occupation. I am taking this course to learn skills related to A new employment field. I am taking this course for non work-related reasons. I declare under penalty punishable by law as a misdemeanor under section 837.06 F.S. that the foregoing is true and correct. ___________________________           Student Signature                                 Date PAID BY Cash Check   Account Number Expiration Date Cardholder's Name Cardholder's Signature________________________________

MAILING ADDRESS Street/PO Box City State County Zip PHONEHome Work BIRTHDATESEX Male Female ETHNIC ORIGIN: (Required by Federal Gov't)   Asian Pacific     American Indian/Alaskan Native    Black, Non Hispanic  Hispanic  Resident Alien White ARE YOU A FLORIDA RESIDENT:   Yes   No DID YOU GRADUATE FROM HIGH SCHOOL OR RECEIVE A GED?   Yes    No    If so, date received

1. Give student information on the form.  (If the student is a young child, the parent may complete, print,
    and sign the form.)
2. Please do NOT fill the box for office use only.
3. Please choose the session and time preferred for class.
4. Send completed registration form and check for $45.00 made payable to Chipola College.
   Please include Drivers License number on your check.
5. Mail to: 
            Chipola College
            c/o Rance Massengill
            3094 Indian Circle
            Marianna, Fl. 32446.
6. Or you can bring your completed form and pay at the Continuing Education Office, Building S.
7. For more information call Rance Massengill at 718-2440 or 718-2473.

 

Classes| Pool

 

Last updated on: July 16, 2008