Spiral/Distance Learning Registration Form

Please Print

Academic Year: /

Mail to: Fax: 360/528-2028

WASBO Call: 800/524-4706
284 Lee St SW Web
Suite 132 E-mail
Tumwater, WA 98501
SSN/SPU ID Number:
(required for IRS reporting purposes)
Name:
Last: / First: / Middle: / Former:
I have taken a course through SPU.
 Yes No / Current Teaching Situation:
Elementary Teacher (grade) ______Substitute Administrator  Not currently teaching
 Secondary Teacher (subject) ______ Other ______
Permanent Address:
Street: / City: / State: / Zip:
Phone:

Work ( ) Cell/Home ( )

/ E-mail:(required for online courses)
Gender: (optional)
 Male
 Female / Ethnicity: (optional) Please select one or more:
 Hispanic or Latino Alaskan Native
 Not Hispanic or Latino  Black or African American
Hawaiian/Pacific Islander / (optional)
 American Indian
Caucasian/White
 Middle Eastern / Asian
Other
(Please Specify origin______)
Birthdate: (mm/dd/yy) Required Information:
U.S. Citizen Non-U.S. Citizen ______
(Required for Web services access) (country)
CRN / Subject Code / Course Number / Course Title / Credits/Units / Course Instructor / Tuition

Contractual Agreement

I understand and agree that when my registration is accepted by Student Academic Services, I have obligated myself to pay for the courses and all other charges related to this registration. If registering by bank card, I authorize SPU to charge my bank card the amount noted below. If I default, I agree to pay all costs and expenses incurred by the University in the collection of any sums due under this registration, including, but not limited to, reasonable attorney’s fee, collection cost and court costs. If these registration fees are sent out for collection by an outside collection agency or debt collector, the University my add a collection fee of at least one-third and as much as double the principle and interest due on the note and may disclose my default and other relevant information to credit bureau organizations. This note shall be governed by the laws of the state of Washington.
If I decide to cancel my registration, or any portion thereof, I will do so in writing to Student Academic Services. I understand that the date I officially withdraw will determine the amount of refund, if any, that I will receive.
I understand that non-admitted students may take no more that 20 credits per quarter. I also understand that these include all credits taken at other institutions and that any credits taken in excess of these limits will be disallowed. These and other matters are covered in detail in the SPIRAL Bulletin, copies of which are available free of charge from the School of Education--Continuing Education office: 206/281-2274.

I request registration for the courses indicated. I have read and agree to the above contractual statement, which outlines my responsibilities to the University.

X Signature ______Date: ______

Payment method and additional services

Payment Options: Choose one of the following methods (A-C). Payment or copy of the PO must be received at the time of registration.
ACheck enclosed for: Full Payment of $______(Make all checks payable to SPU; Do not send cash)
B Purchase Order Number______from______
(Name of school, district or organization)
______
______
(Address)
PLEASE NOTE: Student is responsible for charges until purchase order is processed. A copy of the PO should be attached.
CCredit Card charge to:  Visa MasterCard ______-______-______-______/_____
(Account Number) (Expiration Date)
Charge full amount of $______to my bank card.
Cardholders Name:______
XSignature:______
I would like a receipt for payment sent to me