You may use this form for all programs offered by BACE. Registration will be confirmed upon receipt of payment. You
may duplicate this form as many times as needed.
Cancelled courses and changes:
Classes which have not filled minimum enrollment 7 days prior to the first class may be
cancelled. In the event of a course cancellation, you will be notified and your registration fee refunded. The College also
reserves the right to change instructors.
Mail this form to:
Business and Community Education
Sauk Valley Community College
173
Illinois Route 2
Dixon, IL 61021
Telephone:
815-835-6212
Fax:
815-288-6032
Social Security Number or Sauk ID Number
Name _________________________________________ _______________________________________ _________
(
Last)
(
First)
(
MI)
Address ________________________________City_______________________ State _________Zip ______________
Home/Cell Phone _________________________ Business Phone ___________________ County _________________
E-Mail Address: ____________________________________________________________________________________
Maiden Name:______________________ Sex: _______ Male _____Female Birth Date:______/_________/___________
This information is required for state and federal reporting and will not be used to determine an individual
s acceptance at Sauk Valley Community College.
Ethnic Description
Student Intent (check one)
Highest Degree Earned
Veteran Status
___
Asian Pacific Islander
___
Prepare for new or first occupational career
___
GED
___
Non-Veteran
___
American Indian
___
Improve present occupational skills
___
High School Diploma
___
Veteran
___
Alaskan native
___
Explore courses for career decision
___
Some College, no degree ___Reservist
___
African American
___
Prepare for transfer to 4-yr institution
___
Certificate
___
Hispanic
___
Remedy basic skills deficiency
___
Associate Degree
___
White Non-Hispanic
___
Pursue non-career, personal interest
___
Bachelor Degree
___
Hispanic Origin
___
Prepare for high school diploma equivalency test
___
Masters Degree
___
First Professional Degree
___
Doctorate Degree
____
Own business?
____
Disabled?
___
Other
___
None
CRN
Course name
Amount Due
$
Total Due $____________
Bill Company:
Company Name: ___________________________________________________ Attention To:__________________________________________________________
Address: _________________________________________________________ City: ______________________________State:_________ Zip: _______________
Date:
Received by:
Cash
Check
Credit Card
Bill Company
SVCC provides equal opportunity and affirmative action in education and employment for qualified persons regardless of race, color, national origin, ancestry, age,
gender, marital status, disability, military status, or unfavorable discharge from military service. Complaints and inquiries related to this policy or any potential
discriminatory concerns may be addressed to: Coordinator of Business and Community Education, Sauk Valley Community College, 173 IL Route 2, Dixon, IL 61021,
815/288/5511.
Business and Community Education
REGISTRATION
Method of Payment: ____ check/money order ____ cash
____
VISA ____MC ____ Discover
____
American Express
credit card number
Expiration date: ______ month ______ year
Security Code__________
Signature: __________________________________________________
22 •
Registration Form