Register for Winter Session

Student ID:

Course Type:

PERSONAL DATA

Prefix:

Select One Miss Mrs. Ms. Mr.

First Name:

Last Name:

*

Middle:

Suffix:

Date of Birth:

Month January February March April May June July August September October November December

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 *

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

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:

Select One Single Married Divorced Separated Widowed

Religion:

Islam
Jewish
Protestant
Baptist
Luthern
Presbyterian
UCC
United Methodist
Other Protestant
Roman Catholic
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:

*

Month January February March April May June July August September October November December

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