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Enrollment Form
Required Items. Please read the cancellation policies.

ERSEA Institute: Eligibility, Recruitment, Selection, Enrollment & Attendance

Student Information:
1st Student Name:
1st Student Email:
2nd Student Name:
2nd Student Email:
3rd Student Name:
3rd Student Email:
 

Agency Information:
* Agency:
Contact Name:
* Job Title:
* Phone:

Fax:

Address:
City:
State:
Zip:
 

Course Information:

* Course::
* Number of Students:

Course 

Cost:

$325 per person  (New Web Price Only!)
* Fees:

Discounts:

 

Note:

When booking online, Early Bird Discounts are only available with Credit Card registrations! 

Take 3 discount is for 3 or more student registering for the same workshop. 
* Total Fees:
Classes are occasionally cancelled. Please indicate if there is a second date in our schedule which may be acceptable to you. You will not be enrolled in this class without a confirmation by phone and/or email or fax. Please read the cancellation policies.
Alternate Course Date::
Payment Method:
* Method of Payment:
PO#:

 Please bill the company: letter of authorization or purchase order will be faxed to (901) 758-4036. I have read and understand the registration and refund procedures for HSU courses.

Card No.  

Expiration Date

Security Code: (3-digit security code on back of card)

Name on Card:

Authorizing Manager:
Comments:
Need more information? Call 1-888-282-7817

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HSU provides a range of services to allow persons with disabilities to participate fully in educational programs and activities.  If you desire support services, contact the student Access Center at (901) 758-4034.
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