Lifelong Learning Waitlist Form

Your Information

First Name *

Last Name

Email Address *

Phone Number *

Birthdate

Why do we ask for your birthdate?

Having your birth date on this registration allows us to match your registration with your record on file at Lourdes University and allows us to better communicate with you in the future. We do not publish or share this information, it is for internal use only.

Billing Address

Country

Street

City

Region

Postal Code

Please list which Lifelong Learning events you would like to register on the waitlist for (i.e. “membership, class A, trip B”)

Payment Information

Payment Amount

Would you like to pay with an Electronic Funds Transfer or a Credit Card?

Credit Card

Cash

Check

cc fee (Hidden)

Amount Due
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Amount Due

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