Community Edu Online Registration Form Community Education/Workforce Registration Form Step 1 of 6 16% Name* First Last Middle Name* Date of Birth* Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year2016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Social Security Number* Email Address* Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Contact Phone* Is this a* Home Phone Cell Phone Business Phone Would you like to provide a Secondary Contact Phone Number?* Yes No Secondary Contact Phone* Is this a* Home Phone Cell Phone Business Phone Gender* Male Female Are you ( Check all that apply ):* Hispanic or Latino American Indian/Alaskan Native Native Hawaiian or Other Pacific Islander Asian White/Caucasian Black/African American Classes you are Registering for:* Name of Activity Cost Beginning Date Time Location:* Torrington Chugwater Douglas Glendo Glenrock Guernsey Hulett LaGrange Lusk Moorcroft Newcastle Sundance Upton Wheatland Community Education/Workforce Policies Registration Deadline: Unless otherwise noted, registration is ongoing until the class fills or begins. Class sizes are limited and registration is first-come, first-served. Registrations are not complete until payment is received. Cancellations: Occasionally classes are cancelled due to insufficient registration or unforeseen circumstances. All fees will be refunded if Eastern Wyoming College cancels the class. Typically, the decision to cancel a class is made two days prior to the start of class, so register early to prevent cancellations. REFUND POLICY: If you want to cancel your registration, notification is required at least two business days prior to the start of class or the registration deadline, whichever is sooner. Failure to attend is NOT a cancellation. If you have any questions, please call Community Education at 307.532.8213 or 307.532.8323 or Workforce at 307.532.8366. Inclement Weather: In the event of inclement weather, call Eastern Wyoming College – Donna White 307.532.8323, Susie Schaefer 307.532.8213, Wade Bruch 307.532.8366, or your Outreach Coordinator. Do You Agree With The Above Policies?* Yes No How did you hear about this class/trip?* Community Education Brochure Radio Program Newspaper EWC Website Friend Direct Mail Personal Contact Why are you attending this activity?* Certification/Testing Improve job skills Personal enrichment Signature I, on behalf of myself or my child/ward, do hereby agree that the “EWC” Program of Torrington, it’s agents, representatives, successors, assignees, all instructors, coaches, managers, umpires, refereess, their assistants or anyone who prepares the playing courts, SHALL NOT be liable for the injury or death of any participant in the “EWC” Program which results from the individual’s participation in the program. We strongly urge each participant to make sure he/she or their child/ward is covered by their own personal insurance before enrollment in this program. Please Type your name as you would sign it* By my using the e-signature feature of this online form, I represent and warrant without reservation that I have the legal right, power, and authority to agree to all terms contained in the electronic records of this online form on behalf of myself (or on behalf of the individual on whose behalf I am acting, if different). I further agree that my use of the e-signature feature of this online application constitutes an "electronic signature" as defined by the Electronic Signatures in Global and National Commerce Act ("E-Sign") and the Uniform Electronic Transactions Act ("UETA") and that I have formed, executed, entered into, accepted the terms of, and otherwise authenticated the terms specified herein for the use of the e-signature feature of this online form. I agree to the above statement. How would you like to pay for your Class(s)?* Credit Card Check Cash Credit Card Payment For Credit Card Processing Please call 307-532-8213 or 307-532-8323. Check Payment Information You can deliver the check in person at 3200 West C Street, Torrington. The Community Education Office is located in the lower level of the main Tebbet Building, room 134. -Or- you can MAIL your check to: Eastern Wyoming College Community Education 3200 West C Street Torrington, WY 82240 As of this time we do not accept credit cards for our Community Education Classes in Douglas. Payment can be in the form of cash/check by dropping the campus, or the first night of class. Cash Payment Information Cash payments are ONLY accepted in person at 3200 West C Street, Torrington. The Community Education Office is located in the lower level of the main Tebbet Building, room 134. Your registration is NOT complete until payment has been received.