Osher Membership Registration Form

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

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Demographics
Gender*

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Ethnicity*
Are you an Hampton University Alumnus?*

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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 are you filling out this form?

OnlineIn Office Ipad Kiosk

How will you like to make your payment?

Cash (Main Office Users Only)Check (Main Office Users Only)By card machine (Main Office Users Only)

Membership Fees

General Membership DuesPlease enter a short description.

$60.00

Total

$0.00

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Osher Membership Registration