Last Name:   First Name:   Middle Initial:
 Home Address:
 City:      State:  Zip:  County:
 E-mail:  Birth Date:
Gender: Male Female
Emergency Contact:   Name:     Relationship:
                                   Day Phone:   Evening Phone:
Do you have any special needs we should be aware of?
Do you have any medical condition/medication that College officials should know to be helpful in an emergency?
How did you hear about us?
Have you ever been an Ivy Tech student?
 Course # (CRN)  Course Title  Day/Time  Cost

Total Cost:  

REFUND POLICY: If you need to cancel your registration please contact us at least 7 days before the first class meeting to receive a full refund or credit. No refunds or credits will be issued after this time except with documented medical emergencies.

By submitting this form I confirm: To the best of my knowledge, the above information is complete and accurate. In case I am injured, I authorize the officials of this College to take the necessary actions to save my life. Additionally, I agree to comply with the practices of Ivy Tech. I understand that if I knowingly provide false information my enrollment may be revoked and I may incur fines and IRS penalties. I promise to pay to the order of Ivy Tech Community College the full amount of the balance due upon request. It is understood that costs incurred in the collection of a delinquent account, including collection and attorney fees, shall be added to the balance of the delinquent account. It is also understood that lack of payment may result in being withdrawn and prohibited from registering for future terms.