Business / Community > Horizons for Youth > Registration > Registration Form - Main Campus

Horizons For Youth Registration Form Mail Registration Have you ever taken a credit or non-credit course at NCC before? Yes____ No______ Child's Social Security No. __________ BirthDate(mm/dd/yy) ___________ Birth Child's Last Name_____________________________ Child's First Name __________________________ M.I._________________ Street or P.O Box _______________________________________________ City_____________________________ State____ Zip _________________ Parent or Guardian Name _________________________________________ Parent or Guardian Signature _____________________________________ Home Phone Number _____________ Work Phone Number _____________ County_______________ Employer _______________________________ School district where you live: (check one) Bangor Easton Northampton Saucon Valley Bethlehem Nazareth Pen Argyl Wilson Other PA Out of State List city, borough, or township where you live ________________________ check Here if currently enrolled as a high school student. COURSE INFORMATION (COPY FROM COURSE SCHEDULE) ATTACH ADDITIONAL PAGE IF NEEDED Course Code-Section: ___________________________ Course Code-Section __________________________ ___________________________ ___________________________ Course Title,Day,Start Date and Time Course Title,Day,Start Date and Time Course Code-Section ___________________________ Course Code-Section ___________________________ ___________________________ ___________________________ Course Title,Day,Start Date and Time Course Title,Day,Start Date and Time Course Code-Section __________________________ Course Code-Section ____________________________ ___________________________ ___________________________ Course Title,Day,Start Date and Time Course Title,Day,Start Date and Time PAYMENT INFORMATION Please check one: Person Check MasterCard Visa American Express Discover Expiration Date: _______ Enclosed Amount $___________ M/V/D Account No._________________________________________________________ Cardholder's Signature: _________________________________________ FAX your application to 6110-861-5551 (credit card only) Cardholder's Name: __________________________________________ Date: ____________________________________ I understand I am responsible for payment of the above listed courses. Parent/Guardian Signature ____________________________________________ Date _____________________________ Mail to: Northampton Community College Student Enrollment Center 3835 Green Pond Rd. Bethlehem, PA 18020 Note: You will be notified if any of the classes listed above are closed. If all courses are available, you will receive your tuition and fees receipt shortly after mailing this form. We will mail your confirmation within ten days of receipt of your registration and payment. To register by phone, please call 1-877-543-0998; have your course codes and credit card ready. Send health form in with your registration form