Registration Form

Course Information

Senior (over 60 years old)

Brock University Alumni

Course	Course Fee $	HST (13% of Course fee)

Total $

Directions/Map Needed

Personal Information
First Name
Last Name
Brock ID# (Alumni only)
Address 1
Address 2
City
Postal Code
Home Phone	ext
Cell Phone	ext
Work Phone	ext
Employer
E-mail
Year of birth
How did you hear about our courses?
If you chose 'other' above, please specify:
	If you do not wish to be added to our mailing list for future course information and upcoming promotions please indicate by checking this box.

Brock University respects your privacy. We protect your personal information and adhere to all legislative requirements, included in The Brock University Act, 1964, with respect to protecting privacy. We do not rent, sell or trade our mailing lists. The information you provide will be used to deliver services and to keep you informed on the activities of Brock University. If at any time you wish to be removed from any of these lists, simply contact the department concerned at 905-688-5550.

Please be advised, we only receive your registration when payment is made online with a credit card.

Our system does not notify us of any registrations unless a payment has been made.

If you choose to pay by cheque or in person, once payment is received you will be then registered in your selected course. You must register and pay in advance of the course start date.

Thank you for your understanding.

Last Updated: October 21, 2010