registrationform Office Use

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					                                                                                            Office Use Only: Reg Date:________ Initial $_______ Bal. $______
                          Digital Media & Technology Center of Chicago                      Method: ___ PP _ Chs Chk# ______ Conf. Sent______ Initials____
                          Classes Held at the University of Illinois at Chicago

                                                                REGISTRATION FORM
Student: Last Name ___ ______________________                          ___ First ______________               ___    Phone ______________________

Address _______________________ City _____________ State                           _ Zip         Email Address:_               _______                    _

Emergency Contact Name                                      ______________           Phone _                           _ Cell _         __            ___

Address                                  City                       Relationship _               _Does student have any medical condition? _              _

If so, please explain here: _________________________________________________________________________________________

Adult Students Employer                             __       ___ Position                           Work Phone__                       _ Ext. _    ____
                              rd            th
Students in Grades 3 thru 12 Only:
School ______________________________ City____________________ Grade ______                                Age ______     Birth Date ________________

Father Last Name ____________________                       First_________________ Home Phone_______________ Cell Phone_______________

Address ________________________City_______________ State_____ Zip________ Email Address:____________________________

Employer__________________________ Position___________________ Work Phone_____________________ Ext.________________

Mother Last Name _                               _ First                            _ Home Phone                        Cell Phone_                   _

Address                              City                         __ State       __ Zip     _ Email Address:_                                       ___

Employer                       __________ ___ Position                      _               Work Phone__                          _ Ext. _         ____

     NOTE: Class schedule may be changed based upon enrollment. Some classes may be combined and age-appropriately grouped.

                              SATURDAY CLASS SELECTIONS (Check Your Desired Class(es)
             October 15, 2011 – December 17, 2011 (10 weeks)  Registration Deadline: October 8, 2011
Youth (Grades 3 – 5)                                Teens (Grades 6 – 12)
(Returning students may qualify to take Teen classes)
____ Video Game Creation & Animation 1:05 pm – 2:20 pm                          ___ Video Game Creation & Animation I*                1:05 pm – 2:20 pm
___ Xbox 360® Game Design              2:25 pm – 3:40 pm                        __ Xbox 360® Game Design                              2:25 pm – 3:40 pm
Adults (Over 18 years and out of high school) . . . . . . . . . . . . . . . ____ Creating Animated 3-D Characters!*                   3:45 pm – 5:00 pm
Adults (Over 18 years and out of high school) . . . . . . . . . . . . . . . ____ Making Marketable Mobile Apps!                       5:05 pm – 6:20 pm
Adults (Over 18 years and out of high school) . . . . . . . . . . . . . __ Web Design & Animation*                                    6:25 pm – 7:50 pm
*Eligible for .5 High School Credit.                                        ____ Filmmaking** January 7 – May 26, 2012                1:05 pm – 3:40 pm

Tuition and Fees:
Annual Registration Fee:                    $      75.00
Tuition: Alumni Registration     $ 550.00 (Payment Arrangement: $285 by October 1 and Oct. 21, 2011)
Regular Reg. w/Grant             $ 599.00 (Payment Arrangement: $310 by Oct. 8 and Oct. 21, 2011)
Film Production w/Grant**        $ 849.00 (Payment Arrangement: $424.50 by November 15 and January 5, 2012)
Regular Reg. w/o Grant           $1198.00 (Payment Arrangement: $610 by October 1 and Oct. 21, 2011)
                     Matching Grants for Regular Tuition as Available. Tuition Increase anticipated for January, 2012.

Agreement
I wish to initially pay     ____Full Amount $_________               _____Payment Arrangement $_________               You will receive a PayPal invoice.

I have received a copy of, read, and agree to the GenTech Policies & Procedures. I also agree to pay all tuitions and fees for the classes for
which I am registering:

______________________________                             _______________________________                    _____________________
Parent or Adult Student Signature                          Parent or Adult Student Name PRINTED               Date

Complete and pay online at www.mygentech.net. OR Return via email to Info@mygentech.net and receive a PayPal invoice.
                       Questions? Call 773-324-7772 or Email Info@mygentech.net. Thank You!

				
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