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USM Dual Credit Course Registration Form

Dual Credit Course Registration Form

Have you previously enrolled in a University of Saint Mary course?

Have you previously enrolled in a University of Saint Mary course?

USM Student ID Number:

First Name:

Last Name:

Street Address:

Street Address Line 2

Street address line 3

City:

State:

ZIP Code:

Country:

Date of Birth:

Social Security Number:

Gender:

Gender:

Female
Male
Coed/Prefer not to Answer

Ethnicity:

Ethnicity:

Not Hispanic/Latino
Hispanic/Latino

Race:

Race:

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

Home Phone:

Mobile Phone:

Personal Email Address:

Citizenship Status:

Citizenship Status:

Citizen of US
Unknown
Nonresident Alient
Resident Alien

Your High School:

Your High School Representative's Name (teacher, counselor, etc.):

Please select the first course you would like to enroll in:

If you would like to enroll in an additional course, please select it from the list below:

Parent/Guardian's First Name:

Parent/Guardian's Last Name:

Parent/Guardian Phone #:

Emergency Contact First Name:

Emergency Contact Last Name:

Relationship to Emergency Contact:

Emergency Contact Phone #:

Is the student listed above currently 18 years of age or older?

Is the student listed above currently 18 years of age or older?

The student is currently at least 18
The student is currently under the age of 18

By enrolling in a course at the University of Saint Mary student, I understand that:

· I am bound by the undergraduate catalog, student handbook, and all University policies and procedures.

· I am responsible for payment of all educational related expenses such as tuition, fees, and other related charges by the first day of classes.

· It is my responsibility to access and review my student account on eSpire/My Account Info.

· I am responsible for late fees and collection fees assessed for nonpayment and access to transcripts, diplomas and other educational services will be suspended until full payment is received.

· Federal form 1098-T Tuition Statement will be provided to me electronically on eSpire/My Account Info. Objections to electronic receipt of my 1098T must be submitted to Student Accounts prior to the Federal due date of that form.

· The electronic submission of this form constitutes my official signature as stipulated by the University of Saint Mary and the State of Kansas.

If you accept these conditions and any charges incurred as a result of registering for courses, check the box below, enter your name, and click the "Submit" button.

Your parent or legal guardian must agree to the below and enter an e-signature:

Student's parent or guardian must sign the below agreement:

By enrolling in a course at the University of Saint Mary student, I understand that:

· I am bound by the undergraduate catalog, student handbook, and all University policies and procedures.

· I am responsible for payment of all educational related expenses such as tuition, fees, and other related charges by the first day of classes.

· It is my responsibility to access and review my student account on eSpire/My Account Info.

· I am responsible for late fees and collection fees assessed for nonpayment and access to transcripts, diplomas and other educational services will be suspended until full payment is received.

· The electronic submission of this form constitutes my official signature as stipulated by the University of Saint Mary and the State of Kansas.

If, as the legal adult guardian of the above-listed student, you accept these conditions and any charges incurred as a result of registering for courses, please apply your e-signature below in the form of your First and Last Name, and click the "Submit" button.

Student Signature:

Parent/Guardian Signature:

Date:

12/12/2024