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Rance Massengill
Email:
massengillr@chipola.edu 
Contact Us: (850) 718-2473

Chipola College Pool

 

Swimming Course Registration Form

To register for swim course sessions, please complete the form below and submit it, along with your $55 course fee, using the following directions:

1. Give student information on the form.  (If the student is a young child, the parent may complete, print,
    and sign the form.)
2. Please do NOT fill the box for office use only.
3. Please choose the session and time preferred for class.
4. Send completed registration form and check for $55.00 made payable to Chipola College.
   Please include Drivers License number on your check.
5. Mail to: 
            Chipola College
            c/o Rance Massengill
            3094 Indian Circle
            Marianna, Fl. 32446.
6. Or you can bring your completed form and pay at the Pool.
7. For more information call Rance Massengill at 718-2440 or 718-2473.

Student Name:  
Please Select Class Time:   10 a.m.    7:00 p.m.
Please Select Session:        Session 1  (June 3-6  & June 10-13)        Session 2  (June 17-20 & June 24-27)

Chipola LogoCHIPOLA COLLEGE
Swim Class Application

YOU MUST OFFICIALLY DROP A COURSE THE DAY BEFORE IT BEGINS OR YOU WILL BE RESPONSIBLE FOR ALL FEES!

$5.00 Late Registration Fee

  Please Print

NAME
SOCIAL SECURITY#
Which of the following options best describes your current situation?

I am taking this course to learn skills related to my current occupation.
I am taking this course to learn skills related to A new employment field.
I am taking this course for non work-related reasons.

I declare under penalty punishable by law as a misdemeanor under section 837.06 F.S. that the foregoing is true and correct.

___________________________        

  Student Signature                                 Date

PAID BY Cash Check mastercard.gif (1051 bytes) visa.gif (262 bytes)
Account Number

Expiration Date
Cardholder's Name

Cardholder's Signature________________________________
MAILING ADDRESS Street/PO Box
City State County

Zip

PHONEHome Work
BIRTHDATE
SEX Male Female

ETHNIC ORIGIN: (Required by Federal Gov't)
  
Asian Pacific     
American Indian/Alaskan Native 
 
Black, Non Hispanic  Hispanic  Resident Alien White

ARE YOU A FLORIDA RESIDENT:   Yes   No

DID YOU GRADUATE FROM HIGH SCHOOL OR RECEIVE A GED?
  
Yes   
No    If so, date received

SWIMCRS.jpg (16541 bytes)

Member of The Florida College System 3094 Indian Circle | Marianna, FL 32446 | Phone: (850) 526-2761 | Email Us