Golden West College Community Services 

Registration Form 

ONE REGISTRATION FORM PER PERSON. This form may be reproduced or additional forms are available in the Community Services Office. Confirmation will be mailed as soon as processed. If your registration is received less than seven business days prior to the event, your confirmation may not reach 
you in time, but your space will be reserved for your convenience, if space is available. 

Mail to: COMMUNITY SERVICES REGISTRATION 
Golden West College 
P.O. Box 2748 FAX: (714) 895-8944 
Huntington Beach, CA 92647-2748

For further information call (714) 891-3991 
Make check payable to: Golden West College 
One check per event, please. (Otherwise, you may wait 4 - 6 weeks for refund of your fee for a filled program.) 

LAST NAME
FIRST NAME
MIDDLE INITIAL 
STREET ADDRESS
APARTMENT NUMBER
CITY
STATE
ZIP CODE
DAY PHONE NUMBER
EVENING PHONE NUMBER
GENDER
BIRTHDATE
AGE
SENIOR'S GOLD KEY CARD NUMBER
E-MAIL ADDRESS
(Information is for our purposes only and will not be sold.)
When there are multiple sessions, please enter your First and Second choices for faster processing. 

PROGRAM NUMBER 
FIRST CHOICE
SECOND CHOICE
PROGRAM TITLE 
PROGRAM DATE
FEE 

PROGRAM NUMBER 
FIRST CHOICE
SECOND CHOICE
PROGRAM TITLE 
PROGRAM DATE
FEE 

PROGRAM NUMBER 
FIRST CHOICE
SECOND CHOICE
PROGRAM TITLE 
PROGRAM DATE
FEE 

GRAND TOTAL 

See Registration Information page for REFUND/TRANSFER POLICY at
http://www.gwc.cccd.edu/CSO/pages/RegInfo.html

Method Of Payment 

Check Number
Name On Check
Total Paid $ 

Credit Card 
VISA, MasterCard, Discover, American Express
Expiration Date
Credit Card Number
Authorized Signature
Cardholder's Name
CVV2 Code # (3-digit number in signature line on back of card Visa, Discover and Master Card only) 

College for Kids and Sports Academy
Release and Medical Consent
My child, _________________, has my permission to participate in the College for Kids programs and I release Golden West College, Coast Community College District, and any presenters and assistants from any liability arising from my son's or daughter's participation in said programs. I understand the College does not provide health and medical insurance for the participants. Consent is hereby given to the College 
for Kids presenters and/or supervisors to give or seek medical aid as required in the case of emergency. 

If children are not picked up at the end of each program, an additional fee of $5 will be charged for administrative supervision.
 
I give my permission for any photographs taken of my child to be used in College publications. 


Signature of Parent
Date 


Signature of Parent
Date