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REGISTRATION OPTIONS:

To mail registration forms: COMPLETE this form, PRINT, RESET, and MAIL form to:

OFFICE OF CONTINUING EDUCATION
UNIVERSITY OF SOUTHERN INDIANA
8600 UNIVERSITY BOULEVARD
EVANSVILLE, INDIANA 47712

Checks should be made payable to USI.

For telephone registration using Visa, Mastercard, or Discover cards: CALL 812/464-1989 or 800/467-8600.

To FAX registration forms: COMPLETE and PRINT this form and FAX it to 812/465-7061.

For online registrations: COMPLETE this form and click SUBMIT.


PERSONAL INFORMATION

* Full Name:

First Name

MI

Last Name
* Street Address:

* City, State, Zip:


City

State

Zip Code

* Home Phone Number:

Ex. 8124651080

Work Phone Number:

Ex. 8124651080

Fax Number:

Ex. 8124651080

*Email Address:

 

If registering for a teacher workshop/event, please include the name of your school, what grade and subject(s) you teach in the Organization Name field.  

Organization Name:

Street Address:

City, State, Zip:


City

State

Zip Code

COURSE/CONFERENCE INFORMATION

COURSE NUMBER COURSE/CONFERENCE TITLE FEE
 Example:  FIT700  Trail Hiking 30.00


CHILDREN'S PROGRAMS ONLY
Date of Birth: Ex. mm/dd/yyyy
Grade in Fall 2013:


PAYMENT OPTIONS

PLEASE NOTE THAT THIS IS A SECURE FORM.  TO TAKE ADVANTAGE OF THIS SERVICE, YOUR INTERNET BROWSER MUST SUPPORT SECURE FORMS.

* Payment Method:
* Name on Credit Card:

* Billing Zip Code:

* Credit Card Number: Ex. 0000111122223333
* Expiration Date: Ex. mmyy (do not include "/")
* CVV Number: How to find your CVV number
Total Fee: $
Please use the area below to explain any information you would like us to be aware of concerning your payment or special requirements you may have.


REFUND POLICIES
Course Cancellation-
Noncredit courses are offered on a cost-recovery basis.  Normally, courses which have not reached their minimum enrollment by one week before the starting date will be canceled and full refunds issued to registrants.

Course Withdrawal-
Courses which meet for three or more sessions:  When you notify us of withdrawal before the second class session you will be charged a processing fee of 15% of the fee paid, not to exceed $15, plus the cost of any materials received.
Courses meeting one or two times:  If you notify us of withdrawal by close of business on the day prior to the program you will be charged a processing fee of 15% of the fee paid, not to exceed $15.  No refunds can be made after the course begins.  Substitutions are usually permitted--call 812/464-1989 to arrange a substitution.
Travel/Study programs, conferences, off-campus workshops, etc. have specific refund policies based upon each program's unique nature.  Call 812/464-1989 to inquire about specific programs.

Refunds for check payments are made by check; refunds for credit card payments are credited to your account.


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8600 University Boulevard - Evansville, IN 47712-3596 - 812/464-8600

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