GRADUATE CREDIT REGISTRATION FORM

offered by Colorado State University
for Annenberg Channel's 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 ___________________ Email address ___________________

Office Telephone _______________________

Please check the 2-credit workshop (tuition at $85 per credit or $170 total) in which you are enrolling:

_____ Insights Into Algebra 1

_____ Learning Science Through Inquiry

_____ Mathematics: What's the Big Idea?

_____ The Missing Link

_____ Private Universe Project in Mathematics

_____ Private Universe Project in Science

_____ Reactions in Chemistry

_____ Science in Focus: Energy

_____ Science in Focus: Force and Motion

_____ Science in Focus: Shedding Light on Science

_____ The Science of Teaching Science

_____ Teaching Math (Online)  -  Specify grade band:
                          K-2___
                          3-5___
                          6-8___
                          9-12___

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

_____ Essential Science for Teachers: Earth and Space Science

_____ Essential Science for Teachers: Life Science

_____ Essential Science for Teachers: Physical Science

_____ The Habitable Planet (Note: Course number is NSCI696)

_____ Rediscovering Biology (Note: Course number is NSCI696)

_____ Learning Math: Data Analysis, Statistics, and Probability

_____ Learning Math: Geometry

_____ Learning Math: Measurement

_____ Learning Math: Number and Operations

_____ Learning Math: Patterns, Functions, and Algebra

_____ Mathematics Illuminated

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.