Continuing Education Cooperative Registration

Continuing Education Cooperative Registration

(Graduate Credit Only)

(Blue or Black ink)

Name

Last First Middle name Maiden

Social Security Number (required): / / r Male r Female

Street Address

City State ZIP County

Home Phone ( ) Work Phone ( )

E-mail (required for online grade access): Birth Date / /

required

Secondary E-mail:

Employer Title

U.S. Citizen: r Yes r No If no, what is country of citizenship? Visa type: r Work r Student

Do you hold state teaching certification? Yes  No

Ethnicity (optional) – Check one:

r African-American (1) r American Indian/Alaskan Native (2) r Asian/Pacific Islander (3) r Hispanic (4) r Caucasian (5)

Education: (Required Information)

r Bachelor Degree Year College/University

r Master Degree Year College/University

r Ph.D. Year College/University

Signature ______Date ______

Continuing Education Cooperative Enrollment

Course #

/

Title

/ Dates / Credit
EDT 7167 / Data Quality Certification-Administrator
Kateri Grillot
KSDE / Aug. 22 2013 to Dec. 13, 2013
or
Jan. 9, 2014 to Apr.4, 2014 / 1

Method of Payment:

□ Check (make payable to Baker University) : Amount $ ______

□ Credit/Debit Card (payment option online only)

Website: https://bakeru.afford.com/PayNow?StoreId=319

Baker University reserves the right to change the tuition and fee schedule at any time. Tuition is refunded as follows:

A.  Written notification of withdrawal received by Student Services prior to the first class session of a course – full tuition refund.

B.  Written notification of withdrawal received by Student Services prior to the second class session of a course – 90% refund.

C.  Withdrawal after second class session of a course – no tuition refund.

D.  Revised 7/3/12