summer online course registration form - … online course... · summer online course registration...

Summer Online Course Registration Form Email: juliette.mogenson@csupueblo.edu Mail: Colorado State University–Pueblo Phone: 719-549-2392 Extended Studies Fax: 719-549-2438 2200 Bonforte Blvd.

Pueblo, CO 81001-4901

Student Information

CSU-Pueblo PID / Social Security Number: ______________________ Birthdate (m/d/y): ___________________ Gender: _________

Full Legal Name: ______________________________________________________________________________________________ First Middle Last Suffix

Address: ____________________________________________________________________________________________________ Street City State Zip

Phone: ___________________________ Email Address: ______________________________________________________________

Ethnicity (select one): ___Hispanic/Latino, Chicano, Cuban, Puerto Rican, Mexican American ___Non-Hispanic/Latino ___Prefer Not to Answer

Race (select all that apply): ___ American Indian or Alaska Native ___Black or African American (including Africa and Caribbean) ___ Asian, Japanese, Chinese, Vietnamese, Korean, Filipino (including Indian subcontinent) ___Native Hawaiian or Other Pacific Islander (Original Peoples) ___White, Anglo, Caucasian (including Middle East, Persia)

Courses Please select the online course(s) by marking an X next to the course(s) you wish to enroll for the Summer 2018 term.

Course Credits Dates Call #

CHEM 160: Intro to Forensic Science 3 May 14 – June 7 0673

ENG 101: Composition I 3 May 14 – June 21 0674

ENG 102: Composition II 3 June 25 – August 2 0675

EXHP 162: Personal Health 3 May 14 – June 7 0676

EXHP 162L: Personal Health Lab 1 May 14 – June 7 0677

HIST202: U.S. History II 3 May 14 – June 7 0678

PSYCH 151: Human Development 3 June 11 – July 5 0679

I certify that to the best of my knowledge, the information provided is true and complete. I understand that if found otherwise, my registration is subject to rejection. I certify that I am aware of policies concerning Financial Aid, refunds, grading, drop/add procedures, and payment of fees. If I am using Financial Aid, I understand I must comply with Financial Aid policies and deadlines, including Pell Grant regulations and enrollment status. I will need to contact Financial Aid at 719-549-2753 for this information.

Student's Signature: _________________________________________________________________ Date: _____________________

To be completed by Extended Studies Staff

Date received: ____________________Date enrolled in AIS: ________________

Please return form to Extended Studies in LARC 267 or by email to juliette.mogenson@csupueblo.edu.

Financial restriction: ________________Sent information: __________________