University Independent Study Registration Form printable pdf download

Seattle Pacific University

Student Academic Services

3307 Third Avenue West Ste 113

Independent Study

Seattle, WA 98119-1997

(206) 281-2031 FAX (206) 281-2669

Quarter/Year: ____________________________

ID #: _________-________-_________

Last Name: ___________________________________

First: ______________________

Middle: _______

COURSE INFORMATION:

To be completed by the department or instructor

(Please Print)

1. Does this course already exist in catalog? (circle one)

yes

2. If yes, please provide the subject code and number (i.e. PHY 1135): __________________________

3. If no, please provide subject code and circle the correct independent study number according to class level (i.e. BIO 4900):

(subject code) ______________________

(subject number)

4900

6900

7900

4. How many credits is this independent study? ______

5. Location of Independent Study: ______________________________ (If overseas, please note policy #9 on back of form).

Course Title: (no more than 27 characters)

Instructor: (Please print) _____________________________________________________________________________________

AGREEMENT:

To be completed by instructor

1._____ appointments of _____ hour(s) with instructor.

4._____ experiments:

2._____ written reports or term papers.

5._____ of hours/weeks of practical experience.

3._____ books to be read and reported

6._____ other

SIGNATURES

(REQUIRED)

By signing below I certify that I understand and agree to the Contractual Statement available online through the Banner Information System and the Financial

Arrangements and Services found in the Undergraduate and Graduate Catalogs (Catalogs); I agree to pay for the credits and for all charges associated with

this course. I understand that if I have delinquent financial obligations or if any financial obligation is adjudged to be discharged, I will not be permitted to

register or attend classes for subsequent quarters or order official transcripts until such obligations have been satisfied. If I default on my financial obligations,

I agree to pay all costs and expenses incurred by the University in the collection of any sums due under this registration, including but not limited to reasonable

attorney’s fees, collection costs, and court costs. If I decide to cancel my registration, I will do so in writing to Student Academic Services. I understand that

the date I officially withdraw will determine the amount of refund I will receive and is based on the Schedule of Refunds found in the Catalogs.

Student:________________________________________________________________

Date:___________

Instructor:______________________________________________________________

Date:___________

Chair or Dean:___________________________________________________________

Date:___________

Registration Office Use Only

CRN# ____________

Subject Code/Number: ___________________

Registered by: _________

Date: ____________