FLEX! Registration Form

INStrUCTIONS: Complete this Form, Print it, and Mail to the Address Below
                             Use One Registration Form for Each Child

If you are registering with a credit card, try our secure on-line registration.

Tuition and materials fee due at the time of registration

SCHOOL:     GRADE:
Student Name SS#
Home
Address 		Birth Date
City State Zip
Phone - Parent (Home) (Work)

 Cell Phone       Email Address  

Signature X___________________________________________________

Language
Course No. & Section
 LevelStart Date Fee
Late registration fee $15
There is a $15 non-refundable fee for any cancellation TOTAL
Check No. Check issued by
Credit Card # Exp. Date
Cardholder Name "
 
Cardholder Signature ___________________________________________________

Make checks payable to: Bucks County Community College

Return to: Continuing Education, Bucks County Community College,
275 Swamp Rd., Cottage 3, Newtown, PA 18940