Participant and School Information

An * means this field MUST be filled in

Contact Information

First Name*:
Last Name*:
Email*:
Please Retype Your Email Address*:
Primary Phone*:
Alternate Phone:
Emergency Contact Name*:
Emergency Contact Phone*:
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?*
Course Interest*

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.