Osher Lifelong Learning Institute (OLLI)
Registration Form

Complete this section with YOUR personal information, even if you are giving an OLLI membership as a gift.

* = Required field

Select your gender identity:*

Male

Female

Other

Decline to state

Previous enrollment at Cal Poly Humboldt

Have you ever been enrolled at Cal Poly Humboldt?*

YES

NO

Secure Information

Please supply the following information.
This information is submitted via SECURE SERVER, and is requested pursuant to Section 41201, Title 5, Calif. Code of Regulation and Section 6109 of the Internal Revenue Code.

Humboldt ID or Social Security Number

Humboldt ID or Social Security Number (000-00-0000): *

First three numbers

Second two numbers

Last four numbers

Date of Birth

Your date of birth is required so that Cal Poly Humboldt may identify records that are unique to you.

Month:* Select month January February March April May June July August September October November December

Day:* Select day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year (4 DIGIT):*

Race/Ethnicity Information

Your voluntary response is requested by the Osher Foundation. If OLLI at Humboldt is asked to report only ONE summary race/ethnicity description for you, choose the ONE category below that you want OLLI to report:

Race/Ethnicity Information (choose one category you want OLLI to report)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern

Native Hawaiian or Other Pacific Islander

Northern African

White

Two or more races/ethnicities

Other

Decline to state

Memberships and donations

Your Membership Status Select one membership option for yourself. *
If you are a current OLLI member, check "Current Member," or select another membership option to join OLLI. If you check "Nonmember," a $25 nonmember fee will be automatically added for each course you later select on this form. (Nonmembers will not be able to register for members-only classes.) ** NOTE: OLLI instructors are not considered Cal Poly Humboldt staff or faculty unless currently employed by or retired from the university.
Current Member of OLLI at Humboldt
New Member ($35/year, July 1-June 30)	$
Renewing Member ($35/year, July 1-June 30)	$
Cal Poly Humboldt Staff/Faculty Member ($25/year, July 1-June 30) **	$
Not Yet 50 Member ($35/year, July 1-June 30)	$
Nonmember (Adds $25 fee to each course)	$
Gift Memberships & Donation
To purchase a gift membership for a family member or friend, check the box. Then fill out the information for the gift membership recipient. You don't have to be a member to buy a membership for someone else. To donate, just write in the amount you'd like to donate to OLLI. Thank you!
BUY GIFT MEMBERSHIP ($35/year, July 1-June 30)	$
DONATE TO OLLI: Enter any amount	$

Gift Membership Recipient Information

Thank you for purchasing an OLLI gift membership! Please enter the recipient's first and last names, their email address, and phone number (at least one of these). If you can also answer the other questions, that will make it easier for the OLLI staff to set up your recipient's Cal Poly Humboldt account.

Gift recipient first name

Please enter the recipient's first name.

Gift recipient last name

Please enter the recipient's last name.

Gift recipient email Provide email or phone (at least one is required).

Enter a valid email or fill in the phone field.

Gift recipient phone number Provide phone or email (at least one is required).

Enter a valid phone number or fill in the email field.

To the best of your knowledge, has this person ever been a student/OLLI student/staff/faculty of Cal Poly Humboldt (or Humboldt State University)?

Yes

No

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Please review the above information for accuracy before submitting this registration form. Once you submit this form, you'll be sent to the payment portal.