Non-Matriculated Student Registration Form This form must be completed by anyone who wishes to register for a Graduate course at Emmanuel College prior to formal acceptance into a degree or certificate program. This form must be submitted at least 2 weeks prior to the start date of the session in which you are enrolling. Please complete this form in its entirety.
1. I am registering for a course in the following session:
○ Fall 1 20____ ○ Fall 2 20____
○ Spring 1 20____ ○ Spring 2 20____
○ Summer 1 20____ ○ Summer 2 20____
2. Current Contact Information: ____________________________________________________________________________ Last Name First Name Middle/Maiden Name ____________________________________________________________________ Home Address _____________________________________________________________________ City State Zip Social Security Number: ______________________________ Home E-mail Address: __________________________________________________ Home Phone: ______________________________
Cell Phone: ________________________________
Date of Birth: ____ /____ /_____ Gender (circle one):
Male / Female
3. Emergency Contact Information: _______________________________________________________________________________________ Person to notify in case of emergency Relationship Phone Number
4. Previous Education: List the name of the institution from which you earned your Bachelor’s degree and your date of graduation. You will need to submit proof of degree conferral from this institution (either an official transcript or unofficial transcript is acceptable) prior to registration. Please do not use abbreviations or acronyms for school names. Name of Institution
Degree Date
1