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Noncredit Workshops Registration Form
Please fill out if you are SPAM BOT
Untitled 1
For the Semester FALL SPRING SUMMER
1)    Personal Data: Please PRINT clearly and complete all applicable information

Student ID# (for office use only)

Name  
Address  
Email Address   Home Phone  
Work Phone   Cell Phone  
How did you first learn about our workshops? Please check only one:
  Semester Schedule   Advertisement   Online   Word of Mouth
Gender: Date of Birth (mm/dd/yy)
Female Male     /     /    
Have you taken any courses/ workshops at BCC in the past?       Yes   No If yes, when?  
2)   Courses: Complete the following (up to four noncredit workshops you wish to take).
Note:
Use only the registration fee shown after the workshop number; do not include any additional fees.

Department Example:
WKS

Course Number
Example:
1049
Section
(Example:
 E1)
Registration Fee
(Example: $19)
                         

 

                         

 

Department
(Example: WKS)
Course Number
(Example:
1049)
Section
(Example:
 E1)
Registration Fee
(Example: $19)
                         
                         
3) Payment: Total your COST above and complete the following:
Total Amount Due:
Check# (if applicable):    OR: VISA/MC/AMX/DISC #:  
Name as it appears
on card:
 Exp. Date    

/

     Security Code      
Billing Address of Card: Phone Number (if different from above)
4) Signature: By signing below, you AGREE to abide by the rules and regulations of BCC and accept the courses as indicated. If applicable, your signature also authorizes BCC to charge your credit card as shown above.
Student's Signature   Date    
5) Submit:

MAIL form and check to Community Education & Workforce Development,
Berkshire Community College,
1350 West Street, Pittsfield, MA 01201



or

FAX form (charge registrations only)
to 413-499-3709.