Secondary School Student Enrollment Form
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1SECONDARY SCHOOL STUDENT ENROLLMENT FORM
COLLEGE OF RURAL AND
COLLEGE OF RURAL AND
COMMUNITY DEVELOPMENT
COMMUNITY DEVELOPMENT
FALL
SPRING
SUMMER Year: ___________
PO Box 756500
Bristol Bay Campus
Interior-Aleutians Campus
Northwest Campus
Fairbanks, AK 99775-6500
CHECK YOUR
842-5692 (fax)
474-5208 (fax)
443-5602 (fax)
1-866-478.2721 - phone
Chukchi Campus
Kuskokwim Campus
Other _________________
REGIONAL CAMPUS
907-474-6280 - fax
442-3204 (fax)
543-4527 (fax)
474-6280 (CRCD Reg fax)
Please print carefully and provide all information.
LAST NAME
FIRST NAME
MIDDLE NAME
or
DATE OF BIRTH (MM/DD/YY)
UA ID NUMBER
SOCIAL SECURITY NUMBER
(required if 1st time registering)
CHECK HERE IF THIS IS A CHANGE OF ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
EVENING PHONE
DAY PHONE
PERMANENT PHONE
FAX PHONE
COMPLETE THE INFORMATION REQUESTED BELOW
Gender
US Citizen?
MALE
FEMALE
YES
NO If NO
Nation of Birth
Nation of Citizenship Nationality
VISA Type
Residency
(Physically in Alaska 2 years prior to enrollment and intent to stay in Alaska)
ALASKA RESIDENT - Date residency began __________________________
NON-RESIDENT
MILITARY / NATIONAL GUARD
Ethnicity:
Alaska Aleut
Alaska Eskimo, Inupiaq
Alaska Eskimo, Yup’ik
Alaska Eskimo, other
Alaska Indian, Athabascan
Alaska Indian, Haida
Alaska Indian, Tlingit
Alaska Indian, Tsimpshian
Alaskan Indian, other
Alaskan Native, other
Alaska Native, SE
American Indian (not AK Native)
Black, not of Hispanic origin
Hispanic or Latino
Asian/Pacifi c Islander
White, not of Hispanic origin
Other ____________
Name of High School you are attending: _______________________________________ High School Location: (city/state) ________________________________
When will you graduate from high school? (month/day/year) _________/_________/_________
COURSE INFORMATION
(Please print carefully)
COURSE
INSTRUCTOR or DEPARTMENT HEAD
IF
CRN
NUMBER
SECTION
COURSE TITLE
CREDITS
DEPT.
PERMISSION (Signature or Email required)
AUDIT
0.0
TOTAL CREDITS
I understand that I (or my parents) are responsible for all applicable UAF academic regulations, tuition, and fees whether or
not I successfully complete the course or courses in which I am enrolling.
X
X
STUDENT’S SIGNATURE
DATE
PARENT’S SIGNATURE
DATE
If you anticipate needing an accommodation for any of your classes please contact the UAF Offi ce of Disability Services at (907) 474-5655 (phone), (907) 474-5688 (fax) or
e-mail fydso@uaf.edu.
Offi ce Use Only: Received by:
Date:
CREDITS
FORM OF PAYMENT
COURSE COSTS
(Scholarships/Waivers/Loans)
Attach Credit, PAF or
TUITION
$ __________
$ _________
CASH
$ __________
SPONSORED COURSE FEE
$ __________
Waiver forms
$ _________
CHECK #_________
$ __________
LAB FEES
$ _________
$ __________
MONEY ORDER
$ __________
BOOKS AND MATERIALS
$ __________
$ _________
PAYMENT AUTHORIZATION
$ __________
DEFERRED PAYMENT PLAN
SERVICE FEE
$ __________
$ _________
$ __________
UA TECH FEE
$ __________
0.00
PAID
$ __________
OTHER (describe)
$ __________
___________
0.00
AMOUNT DUE
$ __________
0.00
TOTAL TUITION AND FEES
$ __________
An affi rmative action/equal
opportunity employer and
educational institute
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