PARTICIPANT INFORMATION

(include area code)
Please answer the following:
Male    Female     Decline to state
YES     NO
List all names you have used at HSU. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change)
  -    - 
DATE OF BIRTH (required):*                      
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
$

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Back to the OLLI at HSU website

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