OSHER LIFELONG LEARNING AT SONOMA STATE UNIVERISTY

REGISTRATION FORM

Institute membership of $170 per session, plus a $70 administrative fee, entitles members to take up to four classes each session. Additional coursescan be added for $50 each. Please remember that OLLI membership is not a tuition fee and accordingly cannot be prorated or refunded.

Please call (707) 664-2394 if you have any registration questions.


Please fill out this form, print it, and enroll by fax, mail or phone at the numbers and address below:

Extended Education
1801 E. Cotati Ave.
Rohnert Park, CA. 94928
tel: (707) 664 2394
fax:(707) 664-2613

Please fill in form. When completed, click the SUBMIT button at the bottom to actually send in the data.
(Your application will not be processed without clicking the SUBMIT button.)

All members must complete this section:

Please fill in the term for which you are registering:

Name Telephone

Current Mailing Address

City/State/Zip

Email:

Last 4 digits of Social Security#

Please type "ssu" in this box (security check)

Please check: New student Returning student

List the courses in which you wish to enroll:  (Need to see the courses again? Click here to open a course list.)

Course Title

Day and time of day

Class # (0000)

Personal Information

Please tell us about yourself:

Birth date (mm/dd/yy): Gender:

Are you an alumni of SSU? Yes No

Select highest grade level completed:
High School: College:

BA or BS MA or MS PhD other

In what occupations have you been employed?



How did you hear about the SSU Osher Lifelong Learning Institute?

Other source (please specify)

What types of courses would you be most interested in taking in the future?

Financial Information

HOW TO DETERMINE PAYMENT AMOUNT (STEP BY STEP):

STEP 1:Cost saving annual membership $450
(Only available in Fall term.) Skip to step 3.

STEP 2: For 1 to 4 classes, enter $170 here:
STEP 3: If you checked five or more classes, enter $50 for EACH class beyond the fourth here.

SUB-TOTAL:

STEP 4: SSU Alumni Association members receive a 10% discount on all OLLI courses. If you are a current member, please deduct 10% from your program subtotal above

STEP 5: (Required Fee, including annual memberships)
Enter $70 for campus administrative fee
STEP 6: Add the above boxes for your TOTAL fee here.
STEP 7: Also, my contribution to Friends of OLLI (Separate check or charge, payable to SSUAF, tax deductible)

If paying by check, attach your check or money order to this form and mail to:

Sonoma State University
School of Extended Education
1801 E. Cotati Avenue
Rohnert Park, CA 94928-3609

If paying by credit card: VISA MasterCard Discover Card American Express

Card Holder's Name

Credit Card Number Exp. Date

Signature ______________________________________________________Date _______________________

I agree to abide by the deadlines and policies governing these courses and am responsible for all course fees.
If you are mailing or faxing in this form please sign above (if using a credit card) or attach your check or money order to the form if mailing it in.