HSU OLLI: Osher Lifelong Learning Institute Registration Form

PARTICIPANT INFORMATION
First Name*
Middle Initial
Last Name*
E-mail*
Mailing Address*
Mailing Address Line 2
City*
State *
Zip Code *
Telephone* (include area code)
Mobile Telephone (include area code)
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Telephone*

Please answer the following:
Select your gender: * Male Female Decline to state
Have you been previously been enrolled at HSU? * YES NO
List all names you have used at HSU. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change)
HSU ID NUMBER (Please enter like this: 000 - 00 - 0000): - -
DATE OF BIRTH (required):* Month: Day: Year (4 DIGIT):

MEMBERSHIP STATUS Select one: * Nonmembers: By checking "Nonmember" in this section, a $25 per course nonmember fee will be automatically added for each course you list below.
Current Member of OLLI at Humboldt State University	$
New Member ($35/year, July 1-June 30)	$
Renewing Member ($35/year, July 1-June 30)	$
Nonmember (Adds $25 fee to each course)	$
DONATE TO OLLI: Enter any amount you would like to donate. Thank you!	$

Course Information OLLI at HSU Members: Enter the course information for each course you want to take. Nonmembers: Enter the course information for each course you want to take, and include the regular course fee. By checking "Nonmember" in the Membership Status section, a $25 per course nonmember fee will be automatically added for each course.
Class Number	Course Title/Topic	Fees* Enter numerals only
		$
		$
		$
		$
		$
		$
		$
		$
Subtotal: Fees for Courses		$
TOTAL OF ALL FEES		$

You must enter the image characters below before you can submit this form.
Please check the box to confirm you are a human before you submit this form. You may also be required to verify one or more Recaptcha images. Thank you for helping us prevent spam. *Please review the above information for accuracy before submitting this registration form.*

You must enter the image characters below before you can submit this form.

Please check the box to confirm you are a human before you submit this form.
You may also be required to verify one or more Recaptcha images. Thank you for helping us prevent spam.

Please review the above information for accuracy before submitting this registration form.

OLLI - Osher Lifelong Learning Institute at HSU • College of Extended Education & Global Engagement
Student & Business Services Building, Suite 211 (open Mon.-Fri., 8 a.m.-5 p.m.)
Humboldt State University • 1 Harpst St. • Arcata, CA 95521-8299
phone 707-826-3731 • e-mail olli@humboldt.edu

Osher Lifelong Learning Institute (OLLI)

Registration Form