Retirees Education Program Application Form

1

Please enter your PID # or the last 4 digits of your SS#* This field is required.Your PID # is located on your prescription drug card and your DC 37 membership card

2

Please enter your full name:* This field is required.

First Name

Last Name

3

Address* This field is required.

Street Address

Apartment, Floor, Private House, etc.

City

State

Zip Code

Country

4

Home Phone Number

5

Mobile Phone Number* This field is required.Please note that the Education Fund may text you at this number

6

Please enter a personal email address twice* This field is required.

example@example.com

Confirm Email

7

I have access to the following technology* This field is required.Select all that you have access to

Cellular Phone

Tablet

Computer

8

Course Name & Schedule* This field is required.Select as many courses that you are interested in

Black History - Wednesdays - 1:00 pm - 3:00 pm - Jan. 22 - Mar. 26

Computer Fundamentals - Wednesdays - 10:30 am - 12:30 pm - Jan. 22 - Mar. 26

Digital Literacy - Thursdays - 1:30 pm - 3:30 pm - Jan. 23 - Mar. 27

Health and Fitness (Cynthia Dixon) - Thursdays - 1:00 pm - 3:00 pm - Jan. 23 - Mar. 27

Intermediate Computer Technology - Wednesdays - 1:30 pm - 3:30 pm - Jan. 22 - Mar. 26

Jewish History - Thursdays - 10:00 am - 1:00 pm - Jan. 23 - Mar. 27

Spanish I - Saturdays - 10:00 am - 12:00 pm - Jan. 25 - Mar. 29

Spanish II - Saturdays - 1:00 pm - 3:00 pm - Jan. 25 - Mar. 29