Student-at-Large (SAL) Registration Form

School of the Art Institute of Chicago
Registration and Records
36 South Wabash Avenue, suite 1210
Chicago, IL 60603
Email: [email protected]
Phone: 312.629.6700 Fax: 312.629.6701
Student-at-Large (SAL) Registration Form
Term:
Fall
Spring
Year: _________
Summer
Source Code:
STUDENT INFORMATION
Last Name
First
ID # (If returning)
MI
Address
Apartment
City
State
Zip Code
Home Phone
Mobile Phone
Email Address
Profession
Employer
Work Email Address
Social Security Number
Date of Birth
Undergrad School Attended
Degree
Year of Graduation
Gender:
Subject
Grad School Attended
Degree
Male
Female
Year of Graduation
Subject
Yes
No
Is there a medical/health condition or disability that might require emergency assistance, or special need requiring regular classroom assistance?
Note: If yes, please complete the Allergy History Form and/or Emergency Action Plan form available in the Forms and Downloads section of the website, or email [email protected] with details.
EMERGENCY CONTACT INFORMATION (if different from/in addition to parent/guardian)
PARENT/GUARDIAN INFORMATION
Last Name
First
Last Name
First
Relationship to student
Relationship to student
Email Address
Email Address
Phone
Type:
Mobile
Home
Work
Phone
Type:
Mobile
Home
Work
OPTIONAL
Do you consider yourself to be Latino/Hispanic?
Yes
No
In addition, select one or more of the following racial categories to describe yourself:
Native American
or Alaska Native
Asian
Black or African
American
Native Hawaiian
or Pacific Islander
White
How did you learn about the Student-at-Large Program at the School of the Art intitute of Chicago?
I am a returning student
Colleague
Friend
SAIC Website
Other
COURSE SELECTIONS
Class number
Title
Day(s)
Meeting times
Class number
Title
Day(s)
Meeting times
Class number
Title
Day(s)
Meeting times
Class number
Title
Day(s)
Meeting times
(not Cat/Sec #)
(not Cat/Sec #)
(not Cat/Sec #)
(not Cat/Sec #)
CONTINUING STUDIES ACKNOWLEDGEMENT + AGREEMENT
Registration/Cancellation: I understand that I am financially responsible for the course(s) for which I am registering. A full refund will be granted for cancellations submitted in writing or in person before the second
class. Medical: I give SAIC permission to obtain emergency medical care, hospital, or clinic treatment for me. I hereby waive liability against SAIC for such care and for transportation provided to such locations as deemed
necessary by SAIC. Rules of Conduct: I have read and agree to abide by the SAIC Rules of Conduct as stated at saic.edu/csrulesofconduct. Photo/Video: I give SAIC permission to video or photograph me participating in
instructional and/or social activities at SAIC and to publish such videos or photographs. I agree to the forgoing on behalf of myself/my child or ward.
X
Signature required of student or parent/legal guardian if student is under 18 years of age.
Date
School of the Art Institute of Chicago
Continuing Studies
36 South Wabash Avenue, suite 1210
Chicago, IL 60603
Email: [email protected]
Phone: 312.629.6700 Fax: 312.629.6701
PAYMENT INFORMATION
Note: Payment is due at the time of registration.
Total Due:
Payment:
Check - payable to SAIC
Credit Card
Money Order - payable to SAIC
FOR OFFICE USE ONLY:
ID #
Date Registered
Tuition Remission:
Initials
CREDIT CARD INFORMATION
Student Name
ID # (If returning)
Term
Cardholder’s Name (as it appears on card)
Billing Address:
Address
Apartment
City
State
Zip Code
Phone Number
Card Type:
American Express
Discover
MasterCard
Credit Card Number
Visa
Expiration Date
Security Code
Amount (equal to Total Due above):
FOR OFFICE USE ONLY:
ID #
Process Date
Approval Code
Cashier’s Name
Refund Date
Refund Amount
Refund Approval Code
Yes
No