Conferencing

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College Credit Registration Form

Complete form and send payment for College Credit to:
CSC Conferencing Office
1000 Main Street
Chadron, Nebraska 69337

23rd Annual Excellence in Early Childhood Conference
Last Name	First Name	Middle Name	Maiden Name
Address
Street or PO	County	City, State	Zip
Home Phone Number	Work Phone Number
Marital Status -- Single Married	Sex -- Male Female
Resident -- NE Resident Non Resident	Veterans Benefits -- Yes No	CSC Student -- New Former
REGISTRATION: Please place a mark next to the course for which you are registering.

	Dept. No.	Crs. No.	Sec. No.	Call No.	Credit	Course Title	Days	Time	Time
Undergrad	FCS	440	99	10643	1	Current Issues in Early Childhood	ARR	ARR	Madsen
Grad	FCS	540	99	10644	1	Current Issues in Early Childhood	ARR	ARR	Madsen

Cost
Tuition and Fees Matric Fee Other Housing $ Total Receipt No
High School Graduate -- Yes No	Date of Graduation	GED -- Yes No
Name of High School
Are you seeking a degree from CSC? -- Yes No		If yes: Your anticipated major at CSC?
Do you intend to enroll in the Fall Semester? -- Yes No
Transfer Student -- Yes No		Name of Institution
If you attended college prior to this enrollment, check highest level, in semester hours, completed. -- 0 1—25 26—59 60—89 90+ BA/BS MA/MBA/MS SPECIALIST
Have you ever taken a graduate course from Chadron State College -- Yes No
Are you currently attending another college: -- Yes No		Name of College
Are you now on suspension from another college? -- Yes No	Date	Reason
Race/Ethnic Category (optional reply) American Indian/Alaskan Native Hispanic Asian or Pacific Islander White, Non-Hispanic Black, Non-Hispanic Other
Certification: I hereby certify that all of the above statements made by me are true and complete, and that I have not omitted any relevant information. I agree that I am obligated to pay the tuition and fees related to the classes listed above by the due date.
Signature		Date