Graduate Registration, College of Professional and Continuing Education


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Graduate Student Registration Form

Education Information

Have you ever taken a course at Clark University?

	Yes
	No

Personal Information

Last Name:
First Name:
Middle Name/Initial:

Gender:

	Female
	Male
Date of Birth:

Ethnicity (Optional):

	African American
	American Indian/Alaskan Native
	Asian
	Asian-Sub Continent
	Caucasian
	Hispanic
	Hispanic/Mexican American
	Hispanic/Puerto Rican
	Multiple Ethnicity
	Native Hawaiian/Pacific Islander

Citizenship:

Mailing Address/Contact Information

Address:
City:
State:
Zip Code:

Is this a new address?

	Yes
	No

Home Phone:
Cell Phone:		Work Phone:
Email Address:

Employer Information

Employer Name:
Address:
City:
State:
Zip Code:
Are you company reimbursed?

Course Selections

Course No.

Course Title

Grade Opt.

Tuition

Registration Fee
Materials/Lab Fee
Late Fee
Total Tuition and Fees

Grade Options: Letter Grade, Audit, or Pass/Fail

Payment Method

This COPACE/Clark University Course Registration requires credit card payment information at the time you submit this form. You MUST call the COPACE office to confirm receipt of this form (508-793-7623) and provide payment information the next business/school day.

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jparent@clarku.edu 950 Main Street, Worcester, Massachusetts 01610 Phone: 508-793-7217