Summer 2017 Registration Form for NON-KU Undergraduate Students

THIS REGISTRATION FORM IS INTENDED FOR USE BY STUDENTS WHO ARE NOT CURRENTLY ENROLLED IN KUTZTOWN UNIVERSITY.

Please see the Student Accounts page for Tuition, Fees, and Payment information. Registration and course enrollment is NOT complete until payment is made in full. You will receive additional information (including account information) and instructions on how to make payment.

Do you hold a degree from a 4-year school? YesNo

If you checked yes, please contact Graduate Admissions to register as a Professional Credits Student.

General Information:

First Name

Middle Name

Last Name

Maiden Name

Street Address 1

Street Address 2

City

State Zip Code

County

Email Address

Home Phone

Cell Phone

Date of Birth:

Gender

PA Resident:

YesNo

U.S. Citizen:

YesNo

Social Security #:
(Optional)

If No, Country of Citizenship:

Name of High School if currently attending:

Kutztown University is committed to assuring equal opportunity to all persons regardless of race, color, religion, national origin, ancestry or gender. This policy extends to employment within and admission to the University and is compliance with all federal laws, including Title IX of the Educational Amendments of 1972.

What is your ethnicity?

Hispanic or Latino
Not Hispanic or Latino

What is your race? (Mark one or more races to indicate what you consider yourself to be.)

White
Black or African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander

Emergency Contact Information:

First Name

Last Name

Phone

Relationship

Summer Session I 2017 (Wed., May 31 – Thurs., June 29) and
10 Week Session (see course description for begin/end dates)

Please note: there is a nine (9) credit maximum per session except for internships.

Housing

If Yes, please contact the Housing Department in Old Main 106.

Meal Plan

Department	Course Number	Section Number	Course Title	Credits

Summer Session II 2017 (Mon., July 10 – Thurs., Aug. 10)