This document is a registration form for the Academy for Lifelong Learning (ALL) at Lone Star College. It collects personal information like name, address, phone number, and emergency contact. It also lists course selections, fees, payment methods, and requires a signature to register for classes.

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: