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Non-Credit Workshop Registration

For 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 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.