Osher Membership Registration Form

How are you filling out this form?

Online via Osher WebsiteOsher Main Office Ipad Kiosk

Would you like to fill out our demographics questions for research purposes?

YesNot at this time

Demographics
Gender*

FemaleMaleDo not wish to answer
Ethnicity*
Are you an Hampton University Alumnus?*

YesNo
If you're an Alumnus of Hampton University, please provide your graduation year and degree:
How did you hear about the Osher Institute?*

Payment

We accept online, cash, and check payments. Cash and Checks may be sent to or dropped of to the main office (W.O. Lawton Building 1006 G Settlers Landing Road | Hampton, Virginia 23668) Checks payable to: * Hampton University | Memo: Osher Lifelong Learning Institute Membership*
How will you like to make your payment?

Cash (Main Office Users Only)Check (Main Office Users Only)In Office Card Machine (Main Office Users Only)

Membership Fees

General Membership Dues

Please enter a short description.

$60.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Osher Membership Registration