Fillable Printable Special Student Registration Form - Evergreen State College

Special Student Registration Form - Evergreen State College

Have you previously attended classes at Evergreen?



Yes, last quarter attended:

Mailing

Address City State Zip

Phone ( ) Alt. # ( ) E-Mail

Social Security Number Date of Birth Sex:



Male



Female

Are you a U.S. Citizen?



Yes WA Resident:



Yes Resident Since (MM/YY):



No Nationality:



Are you Hispanic in origin?



Yes, I am Hispanic in Origin. (Select one or more): (H10)



No, I am non-Hispanic in origin. (H20)

Colombian (707)

Costa Rican (708)

Cuban (709)

Dominican (710)

Ecuatorian (Ecuadorian) (711)

Guatemalan (716)

Honduran (718)

Mexican or Mexican-

American (Chicano) (722)

Nicaraguan (723)

Panamanian (724)

Peruvian (726)

Puerto Rican (727)

Salvadoran (712)

Spanish (730)

Uraguayan (734) Venezuelan (735)

Other Hispanic Origin (H10):

How do you describe your race? (Select one or more):

American Indian (Select one or more):

Chehalis (020)

Chinook (055)

Colville (159)

Cowlitz (027)

Duwamish (031)

Hoh (052)

Jamestown (023)

Kalispel (156)

Kikillus (032)

Lower Elwha (024)

Lummi (028)

Makah (053)

Muckleshoot (034)

Nisqually (035)

Nooksack (029)

Port Gamble Klallam (025)

Puyallup (036)

Quileute (051)

Quinault (050)

Samish (037)

Sauik-Suiattle (038)

Shoalwater (492)

Skokomish (079)

Snohomish (041)

Snoqualmie (042)

Spokane (160)

Squaxin Island (043)

Steilacoom (044)

Stillaguamish (045)

Suquamish (045)

Swinomish (047)

Tulalip (048)

Upper Skagit (039)

Yakima (078)

Other American Indian (R13): ________________________________________

Alaska Native (Select one or more):

Alaska Aleut (Unangan) (941)

Alaska Alutiiq (942)

Alaska Athabaskan (014)

Alaska Eskimo (Inupiaq or Yupik) (935)

Alaska Eyak (943)

Alaska Haida (016)

Alaska Tlingit (017)

Alaska Tsimshian (018)

Other Alaska Native (950):

Asian (Select one or more):

Asian Indian (600)

Bangladeshi (601)

Bhutanese (602)

Burmese (603)

Cambodian (Kampuchean) (604)

Chinese (605)

Filipino (608)

Hmong (609)

Indonesian (610)

Japanese (611)

Korean (612)

Laotian (613)

Madagascar (639)

Malayan (614)

Maldivian (634)

Mongolian (624)

Nepali (635)

Pakistani (616)

Singaporean (637)

Sri Lankan (617)

Taiwanese (606) Vietnamese (619)

Thai (618) Other Asian (R20):

Black or African American  (R30)

Native Hawaiian or Other Paciﬁc Islander (Select one or more):

Fijian (676)

Guamanian (660)

Kosraean (667)

Mariana Islander (661)

Marshall Islander (662)

Micronesian (669)

Native Hawaiian (653)

Palauan (663)

Papua New Guinean (678)

Ponapean (Pohnpeian) (670)

Samoan (655)

Solomon Islander (679)

Tahitian (656)

Tarawa Islander (672)

Tokelauan (659)

Tongan (657)

Trukese (Chuukese) (674)

Vanuatuan (New Hebrides Islander) (680)

Yapese (675)

Other Paciﬁc Islander (R40):

White (includes people of European, Middle Eastern, or North African descent)  (R50)

SPECIAL STUDENT REGISTRATION FORM



FALL



WINTER



SPRING



SUMMER YEAR

Evergreen ID# A

Legal Name

Last First Middle

FOR OFFICIAL USE ONLY



NonResident



Resident



TOTAL

CREDITS

Late fee?



YES $50 $100

Student Accounts

OK to reg?



YES



Financial Aid

OK to reg?



YES



OFFERING TITLE

Faculty Signature (If required by faculty

or adding after the quarter begins)

CRN

(Course Reference Number)

number of credits per quarter

F W S SU

OFFERING TITLE

CRN

(Course Reference Number)

number of credits per quarter

F W S SU

ADDDROP

Emergency Contact Phone ( )

Name/Relationship

Address

Last School Attended

Name of School City/State Ending Period (MM/YY) Diploma/Degree

Are you a military veteran?



Yes



No Are you eligible for federal dependant/veteran beneﬁts?



Yes



SPECIAL STUDENT REGISTRATION FORM

Please complete ALL ﬁelds.

Evergreen will release directory information to outside inquiries upon request unless you indicate conﬁdentiality. Evergreen deﬁnes directory information as

the student’s: name, address, telephone number, place and date of birth, major or ﬁeld of study, dates of attendance, degrees received, participation in sports,

and most recent educational institution attended. Do you allow Evergreen to release directory information?



YES, ALLOW



NO, CONFIDENTIAL

TOTAL CREDITS

I understand and accept the registration and payment policies of The Evergreen State College.

Signature Date

FOR OFFICIAL USE ONLY

INITIAL DATE



OLY



TRIBAL

