Pathways Institute for Lifelong Learning®

RegistrationForm

Spring 2017

*Please COMPLETE All Sections and PRINT All Information*

(One Form Per Person)

Please select one of the registration options below.

Membership Option  Per Course Option

Refer to Pathways Institute catalog Membership Informationfor registration details & options.

Name: Dr. Mr. Mrs. Ms. (Circle one)

______

Last Name First Name (preferred)MI

Address:______

StreetCityStateZip Code

Apartment Number: ______Cottage Number: ______

Phone: (______) ______E-Mail Address:______

Please select one:

Community Member...... 

Landis Homes Resident...... 

Steeple View Resident...... 

Instructor...... 

*Membership Fee Covers Enrollment in FiveCourses(Plus Other Benefits Listed in Catalog).

*Membership Fee and Per Course Fees Does Not Cover Special Events, Transportation, Books, Supplies, or Meals.

  • Please do not submit payment with registration.
  • A statement will be issued indicating amount owed along with confirmation of courses and events in which you are enrolled.
  • Payment is due within two weeks of receiving your statement.
  • Issue check or money order to: LANDIS HOMES

SEE REVERSE SIDE TO LIST COURSES & EVENTS

Registration Data:

  • Prioritize your selections by listing them in order of importance to you in the section below. Priority is given first to your preferences, and secondly to the date your registration form is received.
  • Every attempt will be made to enroll an individual in their first 5 preferred courses, for Membership option (special events not included). Requests for additional courses will be considered on a space available basis, so it is important to list all courses you are interested in attending in priority order.
  • Please make sure to check the boxes below if you wish to attend the special events. Capacity for these events is limited, so please sign up early!
  • Please do not submit payment with registration. A statement will be issuedindicating amount owed along with confirmation of courses and events in which you are enrolled.Payment is due within two weeks of receiving statement. Make checks payable to Landis Homes
  • Service Projects are notto be counted in your course selections. List them separately below.
  • Please refer to the Fee Schedule for a list of all fees associated with the spring 2017 term.

Priority Order Course # Course & Event Titles (Priority Selections)

1st First Choice
2nd Second Choice
3rd Third Choice
4th Fourth Choice
5th Fifth Choice

Alternate Course # Course & Event Titles (Alternate Selections)

6th First Choice
7th Second Choice
8th Third Choice

Special Events:

Please indicate if you are New to Pathways or are a Returning member.

Please tell us how you first learned about Pathways Institute for Lifelong Learning:

As a Resident of Landis Homes(Mailing)______

FriendRadio

(Newspaper)______Television

(Magazine)______Other ______

Optional – Please indicate your age range (Circle one)

55 – 59 60 – 69 70 – 79 80 – 89 Over 90

Please indicate your gender (Circle one) Male Female