Student: Please complete the following information

First Name:

Last Name:

Student ID:

Major:

Semester:

Permanent address:

Zip:

City/Town:

State

University Email Address:

Telephone:

Have you been accepted, admitted, and matriculated into a program?

YesNo

Emergency Contact Information

First Name:

Last Name:

Relationship:

Telephone:

I confirm that I DO NOT wish to provide emergency contact information at this time. This action will delete all current emergency contact information. For your convenience you can update/verify information on your account.

I am requesting permission to register to the following course:

CRN

Subject (e.g. MAT)

Course Number (e.g. 101)

Section (e.g. 71)

Course Title

Credits

Days

Time

By selecting the "I Accept" button, you are agreeing to sign this form electronically and that your typed signature is the legal equivalent of your manual signature. It is the student’s responsibility to meet all prerequisites and GPA requirements before registering for any graduate course(s). Graduate students may only be a non-matriculated student for ONE semester. Registering for graduate course(s) as a non-matriculated student does not guarantee matriculation and acceptance to Western Connecticut State University. Incomplete forms will not be processed.

I Accept

Student signature (typed):

Contact Information