Continuing Education Online Application

Redlands Community College Continuing Education Application for Wellness Classes & Fitness Facilities Access
This form has been designed for credit/debit card payments. Other payment methods coming soon!

If paying by check or insurance/3rd-party payment, it is recommended you either come
by the Fitness Office in room PE-2 in the gym OR call 405.422.6229 to enroll.
Name:*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Type:*

Cell/Mobile PhoneHome/Landline PhoneI do not have a phone
Phone Number*

Area CodePhone Number (xxx-xxxx)
Email address available?*

Yes - enrollment and payment receipt will be emailed to youNo - enrollment and payment receipt will NOT be emailed to you
Email:*
example@gmail.com
Information Security Item #1*
Please select a six-digit PIN - Redlands values the confidentiality of your information and includes this item to keep it securely.
Information Security Item #2*
Please select a passphrase that may include numbers, letters, and/or symbols - Redlands values the confidentiality of your information and includes this item to keep it securely.
Before enrolling in a Fitness for Life plan, please check the Redlands website for the Fitness Center hours by clicking HERE and then selecting the 'Facilities' tab. Please note that no one under the age of 16 is allowed in the Fitness Center.

All wellness classes meet on Mondays and Wednesdays from 10am to 1045am unless otherwise noted. You may view descriptions of the wellness classes by clicking HERE and then selecting the 'Classes' tab.
Refund Policy: With written request, refunds are available prior to the start of the Fitness for Life membership or wellness class. No refund will be issued once a membership or class has started. Full refunds will be given for memberships or classes canceled by Redlands Community College. Please allow six weeks for refund processing.
How do you wish to pay for your enrollment?*

By credit/debit cardBy check, if enrolling in personBy insurance or 3rd party payment, if enrolling in person

My Products*

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please hand the tablet to the Fitness Team member assisting you.
Fitness Team member ONLY*
Fitness Team Tember: please enter the information necessary for course enrollment and check/3rd party payment. then return tablet to client.
Date*

MonthDayYear
Date
Signature *

Clear
I certify by signing on the line above that I wish to purchase the item(s) selected.
Should be Empty:

Redlands Community College Continuing Education Application for Wellness Classes & Fitness Facilities Access