DEI 100: Welcoming and Belonging

Please provide the requested information below to register or learn more about DEI 100: Welcoming and Belonging course!

First Name

Last Name

Birthdate

Email Address

Phone Number

Would you like to receive text message about DEI 100?

Yes

What is your preferred method of communication? Please select all the apply.

Texting

Phone Call

Mail

Interest Level:

I would like to learn more about this non-credit opportunity.

I would like to register now!

Additional questions

Additional information needed to complete initial registration for this non-credit offering (*required).

Mailing Address*

Country

Street

City

Region

Postal Code

Citizenship*

Are you a Permanent U.S. Resident?

Yes

Social Security Number*

What best describes you?*

High School Attended (if GED earned, please type 'GED')*

High School graduation year*

Emergency Contact Full Name*

Emergency Contact Phone Number*

Preferred Payment Method.* Full payment will be due prior to the first class.

I would like to pay online.

I would like to pay by check.

I would like to make payment arrangements.

Verification*

I am the individual named above.

I understand, that by signing this registration form, I am formally registered for the above indicated semester and have incurred a financial obligation to pay for these courses unless I formally drop the courses in writing prior to the start of the semester. I understand I will need to obtain a Certificate of Residence from my home County Treasurer’s Office within 30 days of the start of classes to receive In State Tuition.

Electronic Signature*