College Credit — Aquinas Lafayette

College Credit Student Registration Form

First Name

Street Address

City

State

Zip

Work Phone

(###)

###

####

Cell Phone

(###)

###

####

Course Information

Name of Course

Course Number

Location Where Held

Course Instructor

How do you want to take the course?

How did you hear about this course?

Emergency Contact

First and Last Name

Work Phone

(###)

###

####

Cell Phone

(###)

###

####

Primary Citizenship

Education History

Date Started

Date which you began your highest education

YYYY

Date Ended

Date you ended your highest education

YYYY

Social Security Number

Did your parents complete college?

Have you ever been convicted of a felony?

Have you ever been placed on academic suspension, academic probation, or expelled from a college or university?

4. Louisiana Residents: I do hereby authorize University of Holy Cross to access and receive my academic records electronically from the applicable State of Louisiana department and/or agency. I also authorize University of Holy Cross to release or receive admissions-related information on as as-needed basis to or from secondary school officials and /or University of Holy Cross officials.

Do you work for the Church?

If so, what is your occupation?

Are you interested in receiving a scholarship?