FILL in your information and print this form.

First Name:

Middle Initial:

Last Name:

Social Security #:

Birth Date:

Gender:

Select One Male Female

Home Address:

City:

State:

Zip:

Home Phone:

Work Phone:

E-Mail Address:

I would like to register for the following classes:

Course Ref.#
(CRN)

Ed2Go
Start Date

Course Name:

Amount Due:

(CRN)

Start Date

Course Name:

Amount Due:

(CRN)

Start Date

Course Name:

Amount Due:

(CRN)

Start Date

Course Name:

Amount Due:

(CRN)

Start Date

Course Name:

Amount Due:

Total Amount Due

Information collected in this section is used to comply with Federal and State reporting requirements.

Hispanic or Latino Ethnicity (select one):*

Yes

No

Race (choose one or more):*

(20) American Indian/Alaskan Native (10) Asian (30) Black or African American

(70) Native Hawaiian/Pacific Islander (50) White (60) Choose not to respond

Primary Race/Ethnicity (select one):*

(20) American Indian/Alaskan Native (10) Asian (30) Black or African American (40) Hispanic or Latino

(70) Native Hawaiian/Pacific Islander (50) White (60) Choose not to respond

Are you in the United States on a Visa-Nonresident Alien? (select one):*

Yes in the United States on a Visa

Not in the United States on a Visa

If Yes, provide Home Country or Origin

Student Intent:*

(01) Prepare for new or first occupational career (02) Improve present occupational skills (03) Explore courses to decide on a career (04) Prepare for transfer to 4-yr. college or univ.

(05) Remedy basic skills deficiencies (06) Pursue non-career, personal interests (07) Prepare for high school diploma equivalence test (08) Other or unknown

Highest Degree Previously Earned:*

(30) GED (35) High School Diploma (39) Some college (No degree) (40) Certificate (45) Associate Degree (50) Bachelors Degree

(60) Masters Degree (70) First Professional Degree (80) Doctorate Degree (85) Other (90) None

Employment Status:*

(01) Full Time - 40 hrs. or more (02) Part Time - over 15 hrs/week (03) Part Time - 15 hrs or less/week

(04) Homemaker (05) Unemployed (06) Retired/Other

Method of Payment

Visa MasterCard Check/Money Order

Discover American Express

(Make payable to Black Hawk College)

Credit Card Number

3 Digit Security Code (located on back of card)

Expiration Date

Signature:

Thank you for your Registration!

PRINT out this form using the File/Print command on your computer.

MAIL with your payment to:
Black Hawk College - Outreach Center
Business & Community Education Center
301 Avenue of the Cities
East Moline, IL 61244

FAX this form with credit card information to: (309) 755-9847

You will be contacted if a class is already full. A confirmation will be mailed to you within five (5) days after receipt of this form.

If you would like to contact us by phone, please call (309) 796-4800, Ext. 8223.