registration form & contact info - Merced College Community Services

REGISTRATION FORM & CONTACT INFO
3600 M St.
Phone: 209-384-6224
MERCED
COLLEGE
COMMUNITY
SERVICES
Merced College
Community
Services
Box 5
Fax: 209-384-6379
Merced, CA 95348
Email: communitysvc@mccd.edu
Mailing
Address:
630
W.
19th
Street,
Merced,
CA 95340
Registration Form
tel 209.384.6224 • communitysvc@mccd.edu
Please use
form per person. • www.mHUFHGFRPPXQLW\VHUYLFHVFRP
faxone
209.386.6793
Please use one form per person
Student Name (Please Print):_________________________________________
Date: __________
Address:__________________________ City: _________________ State: ________ Zip:____________
Phone (home):___________________________ (other): _____________________________
Email: ______________________________________
Session #
Activity Title
Dates of Activity
Visa____ Master Card____
Card Number_________________________ Exp. Date:______ 3-Digit Code______
Signature: __________________________________________
Fee
Balance Due
Method of Payment:
Name of Card Holder: ________________________________
Class Time
Want to skip filling out this form?
Register online at…
www.mercedcommunityservices.com
*NOTE: Our registration office is located
in the downtown Merced College Business
College for Kids Classes, Aquatics, & Sports Camps:
Resource Center, 630 West 19th Street.
From June 15 to July 30,
Student’s Birth Date: _____________ Grade of Student Next Fall: ______
the College For Kids
Parent/Guardian Name:_________________ Work Number: _________________ headquarters & registration
will be located at
Emergency Phone Number: _______________________
Merced College 3600 M Street
in Room Art-2.
(Cash payments can be completed at the Merced College Business Resource Center ONLY )
I have read and agree to the terms of the cancellation and refund policy online at www.mercedcommunityservices.com. Unless otherwise indicated, I
consent to the college's use of any photographs or video that are taken of me or my child while participating in this program for use in publicity
materials. I am aware that during any instructional or travel program certain dangers may occur, including but not limited to the hazards of
accidents or illness. I hereby release, discharge, absolve and agree to hold harmless and indemnify Merced Community College District, its officers,
agents, and employees from any and all liability for injuries, illness, sickness, or disease that may occur while participating in the program.
I hereby give my consent for college personnel to authorize any and all emergency medical and dental treatment.
Student Signature
Parent/Guardian Signature