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Rance Massengill
Email:
massengillr@chipola.edu 
Contact Us: (850) 718-2473

Chipola College Pool

 

Swimming Course Registration Form

To register for swim course sessions, please complete the form below and submit it, along with your $55 course fee, using the following directions:

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 $55.00 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 Pool.
7. For more information call Rance Massengill at 718-2440 or 718-2473.

 


Name: Social Security #
Address: Phone:
City: State:
Zip Code:
E-mail
BIRTHDATE SEX: 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

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 mastercard.gif (1051 bytes)  visa.gif (262 bytes)
Account Number 
Expiration Date 
Cardholder's Name 

Cardholder's Signature________________________________
Fees: $55.00
Receipt No
. ____________________

 


Member of The Florida College System 3094 Indian Circle | Marianna, FL 32446 | Phone: (850) 526-2761 | Email Us