PROGRAM REGISTRATION FORM

Please complete SEPARATE registration forms for EACH PERSON taking a program. Mail this form to: FGCU Academy, 704 Goodlette-Frank Rd. North, Suite 330, Naples FL 34102

Name: Florida Street Address: City / State / Zip: Telephone: Email: Florida residency (Choose one): q Full time q January - May q October - May

I want to join as an Annual Member / $85 (Valid one year from date of purchase) $

PROGRAM FEES: Please note that program fees are different for members and non-members. Enter the CORRECT FEE AMOUNT for each program based upon your membership status. Program #

$ Fee: $

TOTAL: Membership dues (if any) plus program fees: $ q I want to make a donation and support lifelong learning in the SWFL community. $ If paying by check, please send a SEPARATE check for your donation.

I WOULD LIKE MORE INFORMATION ON THE ITEMS CHECKED, PLEASE CONTACT ME: q I am interested in receiving information about the Academy’s travel programs (Brochures available online) q I would like to volunteer q I am interested in being a speaker

PAYMENT q Check (Payable to FGCU Academy) q Credit card: q MasterCard q Visa q American Express q Discover

Name on card: Card number: Expiration date: CVV: Signature: