PLEASE PRINT
CHILD/STUDENT NAME
San Juan College KIDS KOLLEGE REGISTRATION 2016
Last Name
First Name
OR
Middle Initial
CHILD’S SJC STUDENT ID
Address
Street/PO Box
City
State
CHILD’S Social Security Number
Zip
Name of person registering student (parent/guardian) PLEASE PRINT
Work/home/cell (circle one)
£
CURRENT AGE
GENDER
My child has no relevant allergies/medical issues
Start Start
Date Time
Page
Course ID
Email Address
Female
£
SIGNATURE of person making payment
Date
My child has allergies and/or medical issues (additional form required)
SHORT CLASS TITLE
EX AM P L E :
1 6/6 3:10 10 CKMAS 001 A1 Crafts of the Ancients
Fee
RGN DROP Visa/MasterCard/Discover
Date Date OR check # OR Cash (circle one)
$0
3/21
1
2
3
Refund Info
Cash or
check #
INV #
Last four CC # Cash or check #
INV #
Last four CC # Cash or check #
INV #
Last four CC # Cash or check #
INV #
Last four CC # Cash or check #
INV #
Last four CC # Cash or check #
INV #
Last four CC # Cash or check #
INV #
Last four CC # Cash or check #
FO
R
7
FF
IC
6
O
5
E
U
4
Last four
INV # CC #
Initial
LY
SESSION
BIRTHDATE Month/Day/Year
Male £
N
£
O
Work/home/cell (circle one)
SE
PARENT/GUARDIAN NAME
8
9
INV #
Last four CC # Cash or check #
INV #
Last four CC # Cash or check #
Form updated March 2016
OFFICE
USE ONLY
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1
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