Collegium Registration Form

* indicates a required field

College I.D. Number (usually your Social Security Number)

Gender *Female Male

Last Name * First Name * M.I

Address *

City/Town * State * Zip *

Home Phone * Work Phone *
In case we need to contact you with a change in course information.

Birth Date (MM/DD/YY)*

E-Mail Address

Wednesday's Courses:

9:30 am - 10:35 am Session:
10:50 am - 12:10 pm Session:
1:00 - 2:20 pm Session:
2:35-3:35/3:55 pm Session:
Friday courses
9:30-11:30 or later

Membership Fee:

Account Used * MasterCard Visa Discover

Account # * Expiration Date (MM/YY)* Bank Code (What's this?) *

Please click the Submit button ONCE ONLY and wait for the “thank you” page to appear.

Westchester Community College adheres to the policy that no person on the basis of race, color, creed, national origin, age, gender, sexual orientation, or handicap is excluded from, or is subject to discrimination in, any program or activity.