PARTICIPANT INFORMATION

Primary Member Full Name (If you are renewing a supplemental membership)

Please answer the following:

Male    Female
YES     NO
YES     NO
List all names you have used at HSU. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change)
  -    - 
To identify your HSU record, we require you to enter your date of birth:*                      

MEMBERSHIP STATUS

Select one: *

Nonmembers: By checking "Nonmember" in the Membership Status section,
a $25 per course nonmember fee will be automatically added for each course you may have listed above.

Supplemental members who are on another person's primary membership
must fill out this form separately and include the name of the primary member.

Current member $
New member ($35/year, Aug. 1-July 31) $
Renewing Member ($35/year, Aug. 1-July 31) $
HSU Alumni Discounted Membership ($25/year, Aug. 1-July 31) $
Renewing HSU Alumni Discounted Membership ($25/year, Aug. 1-July 31) $
New Supplemental member ($25/year, Aug. 1-July 31) $
Renewing Supplemental member ($25/year, Aug. 1-July 31) $
Nonmember (Adds $25 fee to each course) $
DONATE TO OLLI: Enter any amount you would like to donate. Thank you!
$

Course Information

OLLI Members: Enter the course information for each course you want to take.

Nonmembers: Enter the course information for each course you want to take,
and include the regular course fee. By checking "Nonmember" in the Membership Status section,
a $25 per course nonmember fee will be automatically added for each course.

Class Number
Course Title/Topic

Fees*
Enter numerals only

$
$
$
$
$
 
Subtotal: Fees for Courses
$
 
TOTAL OF ALL FEES
$

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If you are still having difficulties, please call 707-826-3731 to register over the phone. (Monday-Friday, 8 a.m.-5 p.m.)

Please review the above information for accuracy before submitting this registration form.

      



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For additional information call (707-826-3731), fax (707-826-5885), or e-mail the College of eLearning & Extended Education.