UFM CLASS REGISTRATION FORM
PRINT FORM, FILL OUT, AND RETURN OR MAIL TO UFM
UFM
1221 Thurston
Manhattan, KS 66502
(913) 539-8763
Student Name
Address
City State, Zip
Day Phone Evening Phone
Social Security Number
No Credit/Credit (mark one)
Age (If under 18 exact age)
Under18 19-24 25-59 60+ (mark one)
Parents Name (If Under 18)
CLASS # SESSION TITLE
LOCATION DATE TIME
Tax Deductible Donation
TOTAL
I Hereby Authorize The Use of My (circle one) VISA MASTERCARD DISCOVER
Card Number Expiration Date
Cardholders Name (please print)
Cardholders Signature
Participant Statistics: (circle one)
KSU Student KSU Faculty Ft. Riley Other
Where Did You Obtain Your Catalog?
A Class That You Would Like Offered In The Future:
I am participating upon my own initiative and upon my own assumption of risk in a University For Mankind program. I hereby agree, for myself and all who may hereafter claim through or for me, to assume all risk of personal harm or injury relating to or resulting from my participation in any or all classes for which I have registered and to hold University For Mankind harmless as to liability for such injury.
Signature Date
(signature of parent or guardian required for minors)
| Date Recieved | | |
| Entered | | |
| Computer | | |
| Method | Amount |
| Check | |
| Cash | |
| Visa | |
| Mastercard | |
| Discover | |