To print this form, use the "print" command in your Web browser (usually located under the "file" menu).
Please refer to the Continuing Education page for additional information.
| Last Name, First Name |
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| Street Address |
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| City & Zip |
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| Home Phone | ( _____ ) ______-__________ |
| Business Phone | ( _____ ) ______-__________ |
| Course # / Course Title |
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| Start Date / Day(s) / Time | ___/___/___ M T W Th F __:____ am/pm |
| Course Fee |
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| Material fee(s) (if any) |
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| (Circle one) charge | check enclosed | |
| Registration Fee | $5.00 Paid on Course #_________ |
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Roslyn School District Senior Discount Gold Card # |
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| Total |
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| Credit Card | (Circle One) Mastercard | Visa |
| Credit Card # |
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| CVC # |
(3-digit security code on |
| Expiration Date |
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| Cardholder's Name (Print) |
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| Cardholder's Signature |
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| I acknowledge that I have read the policy on refunds and credits below. As an adult education student, I understand that instructors are prohibited from giving me personal advice, either in or outside of the classroom and hereby waive any claim against the Board of Education, Roslyn Union Free School District, for loss or damage which I may incur if such prohibition is violated and I in any way rely on such personal advice. | |
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REFUNDS & CREDITS A written request for a refund or credit must be made one week before the first class. Trip refunds must be requested 30 days prior to departure date. For cancellations less than 30 days prior to departure, full or partial refunds are contingent upon the ability to sell the seat. There are no refunds on registration fees, books or supplies. There is no provision for a partial fee for taking one session or part of a course. Making up absences in another section of a course depends entirely on space availability. |
Return form by mail or fax:
Roslyn Adult Continuing Education / P.O. Box 367 / Roslyn, NY 11576
FAX: 516-801-5095
Please be advised that the Board of Education of the Roslyn Union Free School District,
its employees and agents hereby disclaim any and all responsibility for any injury, damage,
or loss whatsoever in connection with any course offered by the Roslyn Adult Education program.
All individuals take such courses at their own risk.
Return to the Continuing Education Page