College for Kids Registration Form (Please copy registration form for each student attending classes.)
Student Name:____________________________________  Date of Birth: __________ Age: ______ Street/Address:_____________________________ City:_______________ State:______ Zip:________
Did you attend College for Kids previous years? Yes ___  No ___
Parent/Guardian’s name:____________________________________________________
Home or Work Phone number(s) during CFK session:____________________________________________
E-mail address:_________________________________ Cell phone:________________________
Child’s Physician’s Name:______________________ Physician’s Clinic/Phone:________________
Please list any medical conditions your child has that MSUM staff should be aware of: 
______________________________________________________________________
______________________________________________________________________
Sessions fill quickly. Please check the course schedule page for an updated list of closed classes.

Class Title

Week

Time

Class Fee
       
       
       

                                                                                                                                                 Total Cost: ______________

 Checks should be payable to MSUM: ___Check/Money Order  ___VISA   ___MasterCard  ___Discover

# __ __ __ __ - __ __ __ __  - __ __ __ __ - __ __ __ __  Exp Date:__ __/__ __       Amount $______________

Signature of Card Holder: _________________________   Card Holder Zip Code ___________       

Parental Release Form
  • I hereby release Minnesota State University Moorhead, College for Kids, and its employees, from any liability arising out of or in any way connected with participation of my son or daughter in program activities and field trips.
  • I give permission to Minnesota State University Moorhead, College for Kids, and its employees, in the event that I cannot be reached at the emergency telephone number above, to transport and admit my child to a local hospital for the purpose of emergency medical treatment.
  • I give permission to Minnesota State University Moorhead to photograph my child for future College for Kids brochures and advertising

Parent's Signature:______________________________________  Date:_______________

Submit form with payment in one of the following ways:                               Questions: 218.477.5862
1- Via US Mail to: MSUM Continuing Studies, Box 82, Moorhead, MN 56563
2.  Via Fax: 218.477.5030
3.  In person: MSUM Continuing Studies Office, 811- 11th St S., Moorhead, MN (corner of 11th St S. and 9th Ave S.)