UNDERGRADUATE REGISTRATION FORM FOR CREDIT & AUDIT COURSES

(Please Print Form)   

Center for Lifelong Learning                                                      Semester:  Fall 20                     

(570) 208-5865

Fax:  (570) 821-5910                                                                DATE:                                       

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Check if recent change:                      Name                           Address                                  Phone

Student Name:                                                                                    SS#                                

                                   First                 Middle                  Last

Address:                                                                  Date of Birth                                     

City                               State                Zip              E-mail address                                   

Home Phone                                               Work/Cell Phone                                                  

Have your filed an official application to a degree program?                Yes                   No

   (if yes, please check)                Associate              Bachelor                                          Major

If working toward a certificate, list area:            Fast Track Secondary Certification

                                                                      Director’s Certificate

                                                                      Child Development Associate National Credentialing

                                                                      Other, List area:                                                 

Enrollment Status:         Current               New             Re-Admit            Transfer            Visiting

Student Name (if different) at time of previous King’s attendance:                                                   

Will this registration complete your degree or certificate?              Yes             No

Alumni Discount (If you or your spouse is a King’s Bachelor Degree Graduate, list name on the degree and year graduated):

Name:                                                                       Year:                                                  

Do you receive company benefits?              Yes           No Employer:                                             

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                                                                                          Advisor’s Signature/ Date