Senior Scholars Program Course Request

Senior Scholars Program Course Request

Spring 2025
Senior scholar, please complete this section of the form.
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Email Address*
Course (please provide course number, section and title)*
A separate form is required for each course. As part of the program, Senior Scholars may be registered for up to two courses each semester.
Instructor's Email Address*
By signing and submitting this form:
- I hereby give my consent to be registered for the above course.
- I am aware that I must remit payment to complete the registration process.
- I am aware that if it is determined that I cannot or choose not to meet the necessary requirements to audit the course, the instructor will notify the Registrar to remove me from the course roster.
- Submitting this request does not guarantee registration into the course. You will receive a confirmation once instructor approval has been received and course registration is Complete.
Student Signature*

Clear
Submitting this request does not guarantee registration into the course. You will receive a confirmation once instructor approval has been received and course registration is Complete.
jon email [email]
registrar email [email]
registrar email [short text]

Instructor Approval: Senior Scholars Program Course Request