GRADUATE CREDIT REGISTRATION FORM

offered by Colorado State University
for Annenberg Media Workshops

Please print all information.

Full Legal Name _______________________________

Social Security # ____________________

Ethnic Origin ______
(Optional)

A = Asian
B = Black, Non Hispanic
H = Hispanic
I = American Indian
W = White, Non Hispanic

Highest Degree Attained___________________________

Gender: Female _______ Male _______

Birthdate (e.g., 12/31/52) ___________________________

Street Address _____________________________________________

City __________________________State_______ Zip __________

Home Phone ___________________________

Office Telephone _______________________

Email Address__________________________

Please check the 2-credit workshop (tuition at $85 per credit or $170 total) in which you are enrolling:
(A separate form is required for each workshop or course.)

_____ Assessment in Math and Science: What's the Point?

_____ Looking at Learning...Again, Part 1

_____ Looking at Learning...Again, Part 2

_____ Principles for Principals

_____ Teaching Reading 3-5

_____ Teaching Reading K-2

Please check the 3-credit course (tuition at $85 per credit or $255 total) in which you are enrolling:

(A separate form is required for each workshop or course.)

_____ The Learning Classroom

For which semester and year: _______________________________
(Please refer to Dates and Deadlines Table to choose the best semester for your needs, regardless of when you view the series.)

Total tuition/fees enclosed ______________
($170 for each 2-credit workshop or $255 for each 3-credit course)

Payment:

_______ Enclosed is a check or money order (payable to Colorado State University).

_______ Please charge my MasterCard, VISA (circle one).

Credit Card #: _______________________Expiration Date: _____________

I certify that, to the best of my knowledge, the information furnished here is true and complete without intent of evasion or misrepresentation. I understand that if it is found to be otherwise, it is sufficient cause for rejection or dismissal.

Signature _______________________________ Date _________________

Mail or fax to:

Attn: Annenberg Media Workshops
Colorado State University
School of Education, Continuing Education Office
202 Education Building
Fort Collins, CO 80523-1588
FAX: (970) 491-7204

Students wanting to withdraw from this workshop must do so in writing postmarked two weeks before the coursework deadline. In order to receive a refund (total tuition/fees minus a $25 processing fee), we need to receive a written withdrawal notice postmarked by the registration deadline. Changing the semester for which credit is received also carries a $25 processing fee, and must be requested prior to the last date of enrollment of the original semester for which you are registered. Please refer to Dates and Deadlines Table.