STUDENT REGISTRATION FORM Please enable JavaScript in your browser to complete this form.I understand that it is my responsibility to read all instructions and questions in this form and that if I withhold, misrepresent, or falsify information on this form, at any time, then your application will be considered incomplete. *YesNoWHO REFERRED YOU? *Friend or colleagueRadio / TVSocial MediaOtherName *FirstLastIF OTHER, SPECIFY BELOW *COURSE NAME *STUDENT NAME *FirstLastADDRESS *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePHONE *EMAIL *DATE OF BIRTH * PLACE OF BIRTH (CITY, STATE, COUNTY, COUNTRY) *NATIONALITY *RELIGION *ETHNICITY *BRING YOUR OWN DEVICEYesNoI agree to bring my own device (i.e., laptop) for this class and will follow instructions given by the instructor on the use of my device.NameSubmit