• Merrillville Adult Community Education Class Registration Form

    Directions: Just fill out this short form and then click "File" on the menu bar for your web browser. Go to "Print" and print this page. Sign the bottom then just fax or mail the page to us at 6701 Delaware Street, Merrillville, IN 46410 and your registration will be completed. This registration form must be either faxed or mailed in order to secure your registration. Please print out one registratioon form for EACH CLASS you want to register for. 
     
    WE DO NOT ACCEPT REGISTRATIONS ON LINE!
     
    YOU WILL NOT RECEIVE A CONFIRMATION FOR YOUR REGISTRATION PROR TO CLASS.
     
     PLEASE REVIEW ALL POLICIES PERTAINING TO CANCELLATION PRIOR TO SUBMITTING YOUR REGISTRATON FOR CLASS. 

     

    Name:
    Address:
    City, State, Zip:
    Work Phone:
    Home Phone:
    Course Code Number:
    Section:
    Course Title:
    E-Mail Address:

    Check Number: (payable to MCSC) - Please include Driver's License Number on check


    Fee:
    VISA Number:
    MasterCard Number:
    Expiration Date:
    Please sign below for credit card authorization. 

    Signature of Card Holder:  ____________________________