AEE Registration Form (to receive an invoice and pay by cheque)
The information requested on this form is collected under the authority of section 33© of the Alberta Freedom of Information and Protection of Privacy Act for the purpose of administering programs offered by the University of Alberta, Augustana Campus. Questions concerning this collection, use or disposal of this information should be directed to: Program Coordinator, phone: 780-679-1502, email: augustanaextendeded@ualberta.ca
Program Information
Please let us know which course(s) you are registering for:
Course Name *
Course Date *
Organization *
Person filling out this form (First and Last Name) *
Person filling out this form email *
Person filling out this form phone number *
PARTICIPANT INFORMATION
Please fill out the following information for each course participant.
Participant #1 First Name
Participant #1 Last Name
Participant #1 Job Title
Participant #1 Email (for delivery of course materials)
Participant #1 Cell Phone (emergency contact)
Participant #2 First Name
Participant #2 Last Name
Participant #2 Job Title
Participant #2 Email (for delivery of course materials)
Participant #2 Cell Phone (emergency contact)
Participant #3 First Name
Participant #3 Last Name
Participant #3 Job Title
Participant #3 Email (for delivery of course materials)
Participant #3 Cell Phone (emergency contact)
Participant #4 First Name
Participant #4 Last Name
Participant #4 Job Title
Participant #4 Email (for delivery of course materials)
Participant #4 Cell Phone (emergency contact)
Please share any important medical or dietary information (list participant name followed by relevant information)
OPTIONAL PERMISSIONS
I give Augustana and their partners permission to take photos or videos of me and to reproduce my likeness in promotional materials, including but not limited to brochures and audio-visual productions.
I give permission for the University of Alberta - Augustana Campus to send me emails that include messages about Augustana Extended Education programs and events. You will be able to unsubscribe to these emails at any time.
How did you hear about this program?
INVOICE AUTHORIZATION DETAILS
*
Required
Legal Company Name *
Address 1 *
Address 2
City *
Postal Code *
Accounts Payable Contact Name *
Accounts Payable Phone Number *
Submit
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