Registration Card - Early College

Last Name
First Name
Middle Initial
Birthdate (mm/dd/yy)
Street Address
City State Zip Code
Daytime Phone Number
Please check one: Cell Home Work
Email Adress
Residency/Rate Codes (Check One)
In-District (residents of Berrien County or Covert Township and residents of South Haven school district)
In-Service area (residents of the State of Michigan or counties of Elkhart, LaPorte, or St. Joseph in Indiana)
Out-of-Service area (residents of other states or other counties of Indiana)
International Student

Register for Classes

1. Subject
   Fee
   Course Reference Number (CRN)
   Course Title
   Credit Hours
2. Subject
   Fee
   Course Reference Number (CRN)
   Course Title
   Credit Hours
3. Subject
   Fee
   Course Reference Number (CRN)
   Course Title
   Credit Hours
4. Subject
   Fee
   Course Reference Number (CRN)
   Course Title
   Credit Hours
5. Subject
   Fee
   Course Reference Number (CRN)
   Course Title
   Credit Hours
6. Subject
   Fee
   Course Reference Number (CRN)
   Course Title
   Credit Hours

Semester Expected to Begin:
Fall - Year
Winter - Year
Spring - Year
Summer - Year

Sex: Male Female
Racial/Ethnic Information Please Select One International American Indian/Alaskan Asian/Pacific Islander Black Hispanic Multi-Ethnic White
Student Status Information High School/Dual Enrollment
Educational Goal Associate Degree

Please Select a Field of Study

Student Signature (please type)
Advisor's Name