Office of Educational Outreach

Print out this page and mail it back to the above address.

Name ( Last, First, Initial ): ________________________________  

Address:______________________________________________

E-Mail:_______________________________________________

Social Security: ________________________________________

Phone:________________________________________________

Person to notify in case of emergency: ______________________

Phone: ________________________________________________

COURSE(S) APPLIED FOR:
Course Number(Prefix & Number): ________  Section Number: _____

Course Title: _______________________ Day & Time: ____________

I understand that this Educard is valid only for the term indicated and that it entitles me to attend selected credit courses on a space-available basis, as indicated above. I further understand that I will not earn credit or be entitled to transcripts for this educational experience. I agree to return all textbooks by the publicized term deadline.

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APPLICANT'S SIGNATURE                                                   DATE