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1. New Member Mail-Only ($15 fee) First Last (please print) Middle Initial First Last Middle Initial City Zip I do not want my name, phone no. and email address on the website roster. OMNILORE A Program of Osher Lifelong Learning Institute at California State University Dominguez Hills REGISTRATION INFORMATION Effective September 2011 to August 2012 Check Boxes Applicable: Current OLLI Member * Summer 2010 Spring 2010 Fall 2009 Renewing Member - give names, but only information that has changed from last year Name E-Mail Spouse (if also registering) Spouse’s E-Mail (If Different) Area Code PHONE ADDRESS Omnilore dues for 2011-2012 remain the same as last year: $120 for individuals and $210 for couples. These dues include a required $30 membership per person in OLLI@CSUDH, which provides additional learning opportunities to our members. For new members only, entering during the academic year, Omnilore fees are prorated (1/3 per trimester) to cover the remaining trimesters of the year; however, the OLLI fee is not prorated.   That is, for Spring and Summer, $90.00 per person or $160.00 per couple.  For Summer only, $60.00 per person or $110.00 per couple. Please make check or money order payable to “CSUDH” Please read and sign: I recognize that OMNILORE is a member driven, peer teaching/learning organization, and I agree to assume my share of responsibility necessary for the success of the program. Signature Spouse Signature (if also registering) Fee: $____(single) - or - $______(couple) Check / Money Order #____________ PLEASE MAIL THIS REGISTRATION FORM AND CHECK TO: Dennis Goodno, Omnilore Registrar, 1617 W. 208th St #2, Torrance, CA 90501 * If you have joined OLLI separately for the period July 2011 thru June 2012 Revised: March 2011