UNDERGRADUATE REGISTRATION FORM FOR CREDIT & AUDIT COURSES

(Please Print Form)   

Center for Lifelong Learning                             Semester:Summer 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:                                                                                                             

City                               State                Zip              Date of Birth                      

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

                                                                         CDA 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