COMMUNITY SERVCIES (FEE-BASED) REGISTRATION FROM
|
-
- |
|
/ / |
|||||||||||||||
|
SOCIAL SECURITY NUMBER |
|
MONTH DAY YEAR |
|||||||||||||||
|
|
|
|
|||||||||||||||
|
|
|
|
|
|
|||||||||||||
|
LAST NAME (Please print) |
|
FIRST NAME |
|
MIDDLE INITIAL |
|||||||||||||
|
|
|
|
|
|
|||||||||||||
|
LOCAL MAILING ADDRESS |
|
CITY STATE |
|
ZIP |
|||||||||||||
|
(
) |
|
(
) |
|
/ / |
|||||||||||||
|
HOME PHONE NUMBER |
|
DAYTIME PHONE NUMBER |
|
BIRTHDATE |
|||||||||||||
|
|
|||||||||||||||||
|
E-MAIL (Please print): |
|
||||||||||||||||
|
|
|||||||||||||||||
|
ENTER APPROPRIATE CODE IN
FOLLOWING QUESTIONS: |
|||||||||||||||||
|
|
|||||||||||||||||
|
GENER: [
] |
1. Male |
2. Female |
|||||||||||||||
|
|
|||||||||||||||||
|
ETHNICITY: Enter code from
below [
] |
|||||||||||||||||
|
|
|||||||||||||||||
|
A=Asian AC=Chinese AI=Asian Indian AJ=Japanese AK=Korean AM=Cambodian AV=Vietnamese AX=Other Asian |
|
B=African American/Black F=Filipino H=Hispanic HM=Mexican, Mexican
American, Chicano HR=Central American HS=South American HX=Other Hispanic N=American Indian/Alaskan
Native |
|
O=Other Non-White P=Pacific Islander PG=Guamanian PH=Hawaiian PS-Samoan W=Whit Non-Hispanic X=Unknown XD=Decline to state |
|||||||||||||
|
|
|||||||||||||||||
|
EDUCATIONAL LEVEL: Enter code from below [ ] |
|||||||||||||||||
|
|
|||||||||||||||||
|
NOT A HIGH SCHOOL GRADUATE: |
|
HIGH SCHOOL GRADUATE
WITHOUT A COLLEGE DEGREE: |
|||||||||||||||
|
1. Not a graduate of, and no longer enrolled in high school 2. Currently enrolled in grade K-12 (special admit) 3. Currently enrolled in |
|
4.
Received a high
school diploma 5.
Received a GED
high school equivalency certificate 6.
Received a
certificate of 7.
Received a
foreign high school diploma/certificate |
|||||||||||||||
|
|
|||||||||||||||||
|
COLLEGE GRADUATE: |
|||||||||||||||||
|
8. Received an Associate degree 9. Received a Bachelor degree of higher |
|||||||||||||||||
|
|
|||||||||||||||||
|
CLASS CODE |
CLASS/ACTIVITY: DEPT/COURSE NO/TITLE |
CLASS/ACTIVITY DATES(S) |
FEE |
||||||||||||||
|
|
ANTHR 848AA ANCESTRAL DNA |
Oct. 18th and Nov. 15th |
$150.00 |
||||||||||||||
|
|
|
|
|
||||||||||||||
|
|
|
|
|
||||||||||||||
Make check payable to:
Mail to: ANCESTRAL DNA WORKSHOP
Office
of Instruction,