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
Street Address
City & Zip
Home Phone	( ___ ) ____-________
Business Phone	( ___ ) ____-________
Course # / Course Title
Start Date / Day(s) / Time	___/___/___ M T W Th F __:____ AM/PM
Course Fee
Material fee(s) (if any)
	(Circle one) charge | check enclosed
Registration Fee	$5.00 Paid on Course #_________
Roslyn School District Senior Discount Gold Card #
Total
Credit Card	(Circle One) Mastercard / Visa
Card #
Exp. Date
Cardholder's Name (Print)
Cardholder's Signature
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.

Return form by mail or fax:
Roslyn Adult Continuing Education / P.O. Box 367 / Roslyn, NY 11576
FAX: 516-625-6440

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.

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