Technology Extension Division Form

Programs

Participant and School Information

An * means this field MUST be filled in

Please select the course you are interested in.*

Contact Information

First Name*:

Last Name*:

Email*:

Email Confirmation*:

Work Phone*:

Alternate Phone:*

Alternate Phone Type:*

Emergency Name*:

Emergency Phone*:

Home Mailing Address

Street Address*:

City*:

State*:

Zip*:

Physical Address, If Different From Mailing Address

Street Address:

City:

State:

Zip:

Payment Information

How is this course being paid for?*

Education

Are you a high school graduate or GED recipient?*

Are you 18 years of age or older?*

Signature Statement

I certify that I have read the collection statement. By signing this Statement, I understand my responsibilities as a participant, student, or parent/legal guardian (if student is under the age of 18), regarding my account. It is my responsibility to ensure that payments are made to my account to cover the costs of my participation. Failure to pay my account with Vermont Technical College could result in my account being sent to an outside collection agency where I will also be responsible to pay reasonable collection costs, including but not limited to attorney's fees, court costs, and other fees.

Electronic Signature

I certify that all of the above information is accurate and complete. I understand that withholding information requested in this form or giving false information may make me ineligible for admission or continuation at a Vermont State College institution.