Community Classroom Series Registration Form - Fall 2009

Payment must accompany this form. Print out and mail or fax to the Friday Center. Please print or type.

Name_____________________________________________________________________________

Mailing Address_____________________________________________________________________

City_________________________________________________State_______Zip________________

Daytime Phone (______)___________________________________

E-mail (please print clearly) ____________________________________________________________

UNC-Chapel Hill uses the Personal ID number (PID) to aid in keeping records for students and participants. If you already have a PID, please enter it. PID #__________________________________________________

If you do not already have a UNC PID, one will be assigned to you. Please provide the following information required for PID number creation:

Gender: M   F     Birth Date______________________________________________________

Are you an alumnus of UNC-Chapel Hill? Yes No. If yes, when did you graduate?_____________

Please indicate the accommodations and/or services you require to participate: ________________________________________________________________________________

List the course(s) you wish to take.  The fee is $50 per course:	Fee
Course name: ______________________________________________ Course #______________	$_________
Course name: ______________________________________________ Course #______________	$_________
Course name: ______________________________________________ Course #______________	$_________
Total enclosed:	$_________

Payment must accompany this form. Payments by credit card may be received by mail, fax, or phone.

Check enclosed payable to the Friday Center (Federal ID#56-6001393).

VISA or MasterCard (Only VISA and MasterCard are accepted. Note that debit cards requiring the use of a PIN for all transactions are not accepted.)