Registration Form

Fill out and print form, then

fax to: 404.727.6001
(American Express, MasterCard, or Visa only)

or mail a check to:
Center for Lifelong Learning
Mailstop 1256/001/1AD
Emory University
Atlanta, GA 30322

Please Type or Print

Name: Male Female

Address:
Street

City State Zip Code

Phone Numbers (please include area code):
Work Home Cell

Fax Email

COURSES: Please include course title(s), starting date, starting time and tuition.
1.

Emory Employee (or employee spouse) Emory Alum Age 62+ Academy for Retired Professionals member

Amount enclosed or authorized: $

Make checks payable to Emory University (mail only), or charge to:
Check VISA MasterCard American Express

Name on Credit Card

Card Number Expiration Date

For additional persons enrolling, please give same information on another sheet. You will be sent a confirmation of your registration via U.S. mail or e-mail.

Click here to register ONLINE. Otherwise, print this page to register by fax or U.S. mail.

Paying with your department's FAS account, use the Emory FAS form instead.

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Registration Form

Fill out and print form, then

Please Type or Print

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