LIFELONG LEARNING REGISTRATION FORM
Mail the completed registration form to BC3 Lifelong Learning, P.O. Box 1203, Butler, PA 16002-1203. Checks should be made payable to Butler County Community College. You will receive a registration confirmation once processed. *
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* STREET ADDRESS * CITY * STATE * ZIP
COUNTY * BIRTH DATE * HOME PHONE WORK PHONE
E-MAIL
Indicates required
STUDENT ID
NAME
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COURSE # COURSE TITLE TUITION Registration Fee Per Semester $2.00 Total Amount GENDER □ I prefer not to answer □ Female □ Male ETHNICITY □ I prefer not to answer □ White □ Black or African American □ Spanish-Surnamed Hispanic □ Asian □ American Indian or Alaskan Native □ Native Hawaiian or Other Pacific Islander
OF PAYMENT □ Check made payable to: Butler County Community College □ Charge My: □ MASTERCARD □ VISA □ DISCOVER □ American Express Card No. Exp. Date CVV Code Signature
□ Check box to receive emailed announcements and special offers.
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