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CBIS Training Registration Form

Name

Today's Date

Training Title and Training Date:

Full Name: Last Name, First, Middle

Personal email:

Work email:

Daytime Phone Number:

Cell Phone Number:

Is texting available?

Yes

No

Address

City

State

ZIP

Have you taken classes with BBCC or CBIS previously?

Yes

No

Please list all previous names you may have registered with at BBCC:

Do you know your student ID#? Please list here, otherwise please ensure all contact information is complete.

Participant Birthdate:

Please check all that apply:

Alaskan or Native American

Chinese

Vietnamese

Japanese

Korean

Other Asian or Pacific Islander

Hispanic

Mexican, Mexican American

White/Caucasian

African American

Other Spanish/Latino (for example: El Salvadorian, Guatemalan, etc)

Other Race (please specify below)

If you selected

Gender

Male

Female

Please indicate if you would like the invoice for this training emailed to you personally using the contact information above?

Yes

No

If your employer is paying for this training, please indicate your department and your position title.

Approving Supervisor Last Name, First Name

Approving Supervisor: Title

Approving Supervisor Daytime Phone

Approving Supervisor Cell Phone

Approving Supervisor email address

Approving Supervisor email address confirm

Billing Information: Company Name

Company Address

Company City

Company State

Company Zip Code

Company phone number

Company email address

Agreement:

By checking this box you are authorizing CBIS to enroll you in the above training and are committing to pay all associated costs.

https://www.bigbend.edu/privacy-policy/ *

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