summer online course registration form - … online course... · summer online course registration...
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Summer Online Course Registration Form Email: [email protected] 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 [email protected].
Financial restriction: ________________Sent information: __________________