CLASS REGISTRATION FORM

STUDENT INFORMATION: Complete the information below. Please print clearly.

Name_________________________________________________________ Former Name (if applicable) _____________________________________ Permanent Address __________________________________ Apt #_____ City/State/Zip__________________________________________________ County of Residence____________________________________________ Gender:  ⃝MALE  ⃝FEMALE Birthdate: (Month/Day/Year)  ______/______/__________Student ID Number______________________________________________ Social Security Number __________________________________________ Phone (home) __________________________________________________ Phone (cell) ____________________________________________________ Email__________________________________________________________ Emergency Contact Name_________________________________________ Emergency Contact Phone________________________________________

 CLASS ENROLLMENT:

CLASS NUMBERINSTRUCTION MODECOURSE TITLEHRSTUITIONFEESTOTAL
      $
      $
      $
TOTAL$

FORM OF PAYMENT:

⃝  CASH/MONEY ORDER:  AMOUNT  $ _________

⃝  E-CHECK OR CREDIT CARD:  AMOUNT  $ __________ 

       NAME:  ______________________________________________________

         CARD #:  ________________________________  EXP.  ________  CVV:  _______

         BILLING ADRESS:  ______________________________________________________________________________________________________

STUDENT AGREEMENT:

⃝  I agree that all information above is accurate and true

⃝  I agree to abide by all ITS Training Institute  policies and procedures.

⃝  I agree to pay ITS Training Institute for tuition and fees and any reasonable collection costs if applicable.

⃝  I understand I owe a $25 cancellation fee if I don’t contact ITS 24hrs to class start date to cancel

Student Signature: ___________________________________________________________________________________________ Date: _______________

Advisor Signature: ____________________________________________________________________________________________Date: ______________