SKC CEU Registration Form 2023-1

Personal Information
Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Date
Social Security Number
Your Social Security Number allows SKC to include this course on your transcript by the Registrar's office. Without your Social Security Number, your CEU education will not be included in your SKC transcript.
Email*
example@example.com
Phone or Cell*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState/Province

Postal/Zip Code
CEU and SKC Background
Have you ever attended SKC as a student?*

YesNo
Have ou ever received CEUs from SKC?*

YesNo
Course Information
Course Title*
Course Title - Hidden*
Course Date*

MonthDayYear
Date
Demographic
Which best describes your ethnicity?*

African AmericanAmerican IndianAsian/Pacific IslanderCanadian/Alaska NativeCaucasianHispanicOther
Tribal Certification and Release
Tribal Affiliation:

EnrolledDescendant
Tribal ID Number
Name of Tribe
Upload proof of Tribal Affiliation

Cancelof
Reservation or Tribal Agency Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Birth

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
You have indicated that you are a descendant of an enrolled tribal member. Please tell us their name(s), tribe, and when they were born.
Mother's Information
Mother's Date of Birth

MonthDayYear
Date
Mother's Maiden Name
Mother's Tribe
Father's Information
Father's Date of Birth

MonthDayYear
Date
Father's Name
Father's Tribe
I hereby grant permission to release Tribal Certification to:

Salish Kootenai College Enrollment Services Department PO Box 70 Pablo, MT 59855
Date*

MonthDayYear
Date
Signature*
Should be Empty:

Personal Information

CEU and SKC Background

Course Information

Demographic

Tribal Certification and Release

Mother's Information

Father's Information