Onsite Registration Form - Colorado State University

School of Education
Onsite Registration Form
Fall 2005
Full Legal Name: ________________________________________________________________________________________
(Please Print)
Last
First
Middle
Social Security Number: _________________________________
Ethnic Origin (Optional) _________
A = Asian
B = Black, Non Hispanic
H = Hispanic
I = American Indian
W = White, Non Hispanic
Gender (F/M) ______
Class Level _________
Undergraduate: 11 = Freshman (0-29 credits)
21 = Sophomore (30-59 credits)
31 = Junior (60-89 credits)
41 = Senior (90+ credits)
44 = Post Bachelor
Graduate:
51 = Seeking Graduate credit but not formally admitted to the
Graduate School
52 = Admitted to Graduate School in Master's Program
61 = Admitted to Graduate School in Ph.D. Program
Birth date (e.g. 12/31/52): ________________________
Current Mailing Address:
Number and Street or Box and Route
City
State
Home Telephone: ____________________________________
Zip
Office Telephone:
Email Address _____________________________________
Have you ever attended Colorado State University? _____ Yes _____ No
In compliance with Colorado State law:
If you are a male born after December 31, 1959, are you registered with the Selective Service? _____ Yes _____ No
Course Information:
MALLETTE, DAWN
ED 695 V 600
INDEPENDENT STUDY/ CURRICULUM: SUPERVISION OF INTERSHIP
REGULAR COURSE
8/7/2005 12/10/2005
Grading Option: Pass/Fail
Location:
VARIOUS SITES THROUGHOUT
COLORADO
Credits:
1-4
Tuition: $50 + Fees: $0 = Total: $50
Payment Information:
Cash ________
Check # ________
Credit Card # ____________________________________________
circle one: MasterCard/VISA
Expiration: ________
I certify that, to the best of my knowledge, the information furnished here is true and complete without intent of evasion or
misrepresentation. I understand that if it is found to be otherwise, it is sufficient cause for rejection or dismissal. In signing this
form, I certify that the courses listed above are correct, that I have read and understand the withdrawal policy on my receipt, and that
I agree to abide by all policies of Colorado State University and the Division of Educational Outreach.
Student Signature: ___________________________________________________
SCHOOL OF EDUCATION COPY
PLEASE ATTACH PAYMENT
Date:
School of Education
Onsite Registration Form
Fall 2005
Student Receipt
Course Information:
Course
Title:
Subtitle:
Dates:
Grading Option:
Credits:
Location:
ED 695 V 600
INDEPENDENT STUDY/ CURRICULUM: SUPERVISION OF INTERSHIP
REGULAR COURSE
8/7/2005-12/10/2005
Pass/Fail
Tuition:
1-4
Fees:
VARIOUS SITES THROUGHOUT
Total:
COLORADO
$50
$0
$50
This document certifies that ____________________________________ is enrolled in the
Colorado State University, Division of Educational Outreach course listed above.
Instructor:
MALLETTE,DAWN
_____________________________________
Instructor Signature
________________
Date
Method of Payment:
Cash ____
Check ____
Credit Card ____
This course will be recorded on a transcript which will be available in December 2005.
Please write to: Records and Registration Office, Colorado State University, 100 Administration Annex, Fort Collins, CO 80523
and send $8.00 per copy. Note: Some school districts will not accept abbreviated course titles as they appear on your official
transcript. Therefore, it is imperative that you keep this copy for proof of complete title information.
Withdrawals/Transfers and Refunds
The following information pertains to procedures and policies of Colorado State University and the School of Education's Office of
Continuing Education which affect your enrollment in Continuing Education courses. It is the student's responsibility to be familiar
with the information provided. Students withdrawing/transferring from academic credit courses may receive tuition refunds, less a
$25 withdrawal fee per course, under the following conditions only:
1. the student's copy of the On Site Registration Form is faxed to the School of Education's Office of Continuing Education
2. the student withdraws/transfers before the first one-third of the class has been
A student withdrawing before the first one-half of the class has been completed will be granted a withdrawal, without a refund,
and will receive a "W" on their transcript. After one-half of the class has been completed, no withdrawal will be allowed; no
refund, and a grade of "F" will be recorded if course requirements are not fulfilled.
The effective withdrawal date is the day on which the student formally notifies the School of Education's Office of Continuing
Education of his/her desire to withdrawal by faxing a copy of the Registration Form to 970/491-7204 and noting the withdrawal date
and placing a student's signature next to the withdrawal date on the front of the form. Refund payments take approximately 6-8 weeks
to be processed and are made in the form of a check. If minimum enrollments are not met, the School of Education reserves the
right to cancel this course. Full refunds are made to those students who are enrolled at the time a course is canceled.
Nonattendance does not constitute a withdrawal.
****STUDENT COPY Please retain this copy for your records****