Registration Form

REGISTRATION FORM

Social Security Number______-____-______ Student Account No.____________________

Semester (Check one)___ Fall___ January___ Spring___ SummerAcademic Year: 19 ____ - ____

Outreach Course Location____________________________________________________________________________

Last Name_____________________________________ First Name & MI____________________________________

Prefix: __ Mr. __Ms.__ Male __ FemaleDate of Birth: ___/___/___Email:______________________________

Permanent Address

No., Street, Apt.______________________________________________City______________________________

State______Postal Code___________>Country (if not USA)________________________________________

Is this a new address? ___ Yes ___ NoTelephone Number () ______-________

For I.P.E.D. Compliance Report (check one)

___ Non-Resident Alien___ Black Non-Hispanic___ Asian or Pacific Islander

___ American Indian or Alaskan Native___ Hispanic___ White Non-Hispanic

Undergraduate Degree Held: _________________________College: __________________________________

City__________________________State_____Postal Code_________Country___________________

Employer's Name___________________________________Address____________________________________

City_____________________________________State______Telephone Number () ______ - _______

Have you ever taken any course(s) for Lesley University credit? ___ Yes ___No If yes, when (dates)?________________

Name under which you were registered at that time:________________________________________________________

Program of Study

A. ___Graduate School of Arts & Social Sciences:___On-Campus___Off-Campus___Distance Learning

B. ___ Lesley College or___ Adult Baccalaureate College:___ On-Campus___Off-Campus___Distance Learning

C. ___ School of Management:___ On-Campus___Off-Campus___Accelerated Program___Distance Learning

D. ___School of Education:___ On-Campus___ Off-Campus___Distance Learning

Advisor's Name_______________________________Advisor's Signature___________________________________

Courses

SAMPLE:
Dept ECOMP
Number 5100
Section 01
Title Computers, Technology & Education

Faculty Jane Smith
Audit No
Credit Hours 3
Repeat Course No

1st Course:Dept ______Number______ Section____ Title________________________________________

Faculty____________________________________Audit____Credit Hours____Repeat Course____

2nd Course:Dept ______Number______ Section____ Title_________________________________________

Faculty____________________________________Audit____Credit Hours____Repeat Course____

Are you taking any other courses this semester?____ Yes____ No

There is no retroactive registration at Lesley University. Registration may be revoked if proper payment is not received. We reserve the right to report and retrieve any Credit Bureau information concerning your financial obligations to Lesley University. I have read and understand Lesley University's refund policy. Lesley University, in keeping with accreditation guidelines, cannot guarantee that credits grants to students will be accepted for transfer into any other school, college, or organization: Lesley credits are accepted at the discretion of the receiving institution.

Student's Signature _____________________________________________Date: __________________________

Method of Payment:___ Cash $_____________ Check $______________ MC/Visa $____________

Card Authorization Number

Name on Card: _____________________________________Exp. Date (not valid without this date):

Cardholder's Signature: _____________________________________________Authorization No.: _____________

If you have been awarded Financial Aid this semester, check and attach a copy of your award letter or promissory note.

OFFICE USE ONLY

Registrar's Office
Processed by ____________________________________Date _____________________

Bursar's Office
Processed by ____________________________________Date _____________________