1. Academy for Lifelong Learning (ALL)
RegistRAtion FoRm
Academy for
Lifelong Learning Fax, mail or deliver this form in person.
Date: _________________ Campus: ❏ LSC-CyFair ❏ LSC-North Harris ❏ LSC-Kingwood ❏ LSC-Tomball ❏ LSC-Montgomery
Year: 20 ______ Term: ❏ Fall ❏ Spring ❏ Summer I am: ❏ Currently an ALL member iD# __________________________ ❏ New
Last Name: ____________________________________________ First:______________________________________ Middle: ______________________________
Previous Last Name: __________________ Preferred E-mail Address:____________________________________________________________________________
Current Address: Address Change? Yes ❏ No ❏
Street: ________________________________________________________________________________________________ Apt. #:__________________________
County: __________________________________________ City:___________________________________ State: _______________________ Zip _____________
Mailing Address (if different)
Street: ___________________________________________ City:___________________________________ State: _______________________ Zip _____________
County: __________________________________________ City:___________________________________ State: _______________________ Zip _____________
Home Phone: _______________________________Business Phone: __________________________________ Cell Phone: _________________________________
Social Security: __________ — _________ — __________ Date of Birth_________/ _________ /________ Gender: ❏ Male ❏ Female
Registration #: Course Title: Class Location: Start Date: Course Fee:
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Emergency Contact Information: Total Fee: _________________________
Name: __________________________________________________________ Relationship: _____________________ Method of
Payment:__________________________
Home Phone: ____________________________________Alternate Phone: ___________________________________
Entered By: ________________________
Student Signature:____________________________________________________________ Date: ________________
Date: _____________________________
............................................................................................................................................................... Code: ____________________________
Payment is due at the time of registration. Make checks payable to Lone Star College System.
Charge to my: ❏ AMEX ❏ Discover ❏ Master Card ❏ VISA Card Expiration Date: ___________ Transaction Date: ____________
Card #: ____________________________________________________________________________________________________Security Code:_______________
Name on Card: _______________________________________ Billing Address (include zip): ________________________________________________________
For information on bacterial meningitis, plese go to www.tdh.state.tx.us
Affirmative Action/EEO College Revised 12/2009 F-0007d www. Lonestar.edu/ALL

2. Member # _________________ Name _______________________________________
Class Listing - continued
Registration #: Course Title: Start Date: Course Fee: