Winter 2015

Student ID:
(please provide if applicable)
Course Type:

Blended Course
Classroom Course
Online Course


PERSONAL DATA
Prefix:
First Name:
*
Last Name:
*
Middle:
Suffix:
Date of Birth:
*
Social Security Number:
e.g. (xxx-xx-xxx)*
Address:
*
City:
*
State:
*
Zip:
*
Country:
*
Email Address:
*
Home Phone:
e.g. (xxx) xxx-xxxx*
Work Phone:
e.g. (xxx) xxx-xxxx

Are you participating in Act 48?*

Yes
No

Are you currently an Alvernia University student?*

Yes
No

Are you taking this course to transfer to another institution?*

Yes
No

If Yes, which institution are you transferring this course to?


COURSE SELECTION
Course 1:
*
Course 2:
Course 3:
Course 4:
Course 5:

OPTIONAL INFORMATION
Gender:

Male
Female

Ethnic Origin:

American Indian or Alaskan Native
Asian
Black/African American
Hispanic
Native Hawaiian or Other Pacific Islander
White/Caucasian
Two or More Races
Other (please specify)

Marital Status:
Religion:

Islam
Jewish
Protestant
Baptist
Luthern
Presbyterian
UCC
United Methodist
Other Protestant
Roman Catholic
Other (please specify)

How did you hear about Alvernia's Winter Session?*

Flyer
Poster
Billboard
Postcard
Website
Email
Phone Call
Alvernian Ad
Other College Newspaper Ad
Stall Talk
Facebook
Twitter
LinkedIn
Login Screen on Campus
Other (please specify)


SIGNATURE
To the best of my knowledge, the above information is true.
I agree that, if accepted, I will comply with the rules and regulations of Alvernia University.
Signature:
*
*
I acknowledge and accept the tuition fees, as published in the applicable catalogue that will be incurred by this registration request.

Alvernia University complies with all federal, state, and local nondiscrimination laws in the administration of its educational programs and services and in its employment relationships.

* required field




winter 2015

1.888.alvernia
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