Course Registration

    Personal Data

    First Name
    Middle Name
    Last Name
    Address
    Suite/Apt
    City
    State
    Zip

    How is Permanent Residence Established?

    Home address
    Place of registration to vote
    Family's primary residence
    Other
    Cell Phone
    Home Phone
    Email Address
    Date of Birth
    Citizenship

    Ethnicity

    American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
    Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
    Black or African American A person having origins in any of the black racial groups of Africa.
    Caucasian A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
    Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
    Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
    Gender
    If, Prefer to Self-Describe :
    Preferred Gender Pronoun
    Number of Household
     
    Household Income
    Do You Currently Receive Public Assistance?
    Military Status
    Will You Need Reasonable Accommodations to Participate in this Course?

    Have You Previously Attended College?

    Grade Point Average
    Major
    Number of College Credits Earned to Date

    Select Class Course

    Select Payment

      Full Payment: $3,000.00