Better Me Employee Wellness Enrollment
Instructions:
Rochester Institute of Technology
Better Me Fitness
RITemployeeswhohavenotpreviouslyenrolledforacreditclassatRIT,
pleasecompleteallinformationonthisform and submitthecompletedformto
theRegistrars Office, Eastman Hall (Building 1), first floor.Pleasedonotbring
thisformtotheBetter Me Offices.IfyouhavetakenaclassatRITinthepast,
please enrollusingSIS, directions are available on our website.
Global Village, Bldg 400 Room 2280
Phone 585/475-2067
Email [email protected]
RIT promotes and values diversity and
provides equal opportunity to all qualified
individuals regardless of race, color, creed,
age, marital status, gender, religion, sexual orientation, gender identity, gender expression,
national origin, veteran status, or disability.
General
Information
Current or past RIT Affiliation/s:
Request for Social
Security Number
University ID Number: (use social security number if first time at RIT) ___ ___ ___ ___ ___ ___ ___ ___ ___
Your social security number
is used to report your enrollment to the National Student
Clearinghouse and other
lenders. It is also used internally to award and disburse
federal financial aid, and
provide information to the
IRS for Federal tax credit
reporting.
Today’s Date: ________________
q Faculty/Staff q Student q Alumni q Other ______________________
Registration Term:
✔ Spring q Summer
q Fall q Intersession q
Name ____________________________ ___________________________ ___________________
Last
First
Prior Name ___________________ Gender:
Middle
q M q F Birth Date: ___ ___/___ ___ /___ ___ ___ ___
(mm/dd/yyyy)
Home Address (RIT mail will be sent to this address)
Optional Information
Number and Street _________________________________________________
City/State/Zip _________________________________________________
Province/Postal Code _________________________________________________
Country of Origin
__________________ State of Permanent Residence ___ ___
NYS State County of Permanent Residence ________________
Ethnicity q
Hispanic or Latino
q
Not Hispanic or Latino
Race (please select one or more)
q
Asian
q
American Indian or Alaska Native
q
Black or African American
qNative Hawaiian or other Pacific Islander
q
White
Contact Phone and E-mail Information
Day _______/_______-_________ Cell _______/_______-_________
RIT E-mail [email protected]
Course
Selection
If you wish to be identified with a
particular ethnic or racial group,
please indicate how you would
describe yourself.
Please list your Better Me class request(s) below.
CLASS NO.
SUBJECT
CATALOG
SECTION
UNITS
CLASS TITLE
FEE
$50.00
BTRM ________
0 __________________________________________
56545 ________
601 ________
01
Wellness Class Pass
1. __________
____
_______
2. __________ ________ ________ ________ ____ __________________________________________ _______
3. __________ ________ ________ ________ ____ __________________________________________ _______
4. __________ ________ ________ ________ ____ __________________________________________ _______
Payment
After you enroll, your payment options are:
•
in person at the Student Financial Services Office in the University Services Center (USC), 1st floor
•
online at eservices.rit.edu. Your balance shown under current account activity will be the current balance due.
•
by eCheck or paper check without additional fee. A fee is charged for paying by credit card (MasterCard, Visa and
Discover).
For More
Information
Do you have questions or comments regarding the Better Me programs?
• Contact [email protected].
•
Registrar’s
Office Use Only
For information about Better Me employee wellness program visit the Better Me website at rit.edu/betterme.
Date Received _______________________ Date Processed _______________________ Processed by _____________________
PS 10/17/13
REG-Non-Degree Enrollment
Distribution: Please keep a copy for your records. Return original to the Better Me Fitness Program.