Non-Matriculated Undergraduate Student Registration Form
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Office of the Registrar
181 White Street, Old Main 102
Danbury, CT 06810
Non-Matriculated Undergraduate
Phone: (203) 837-9200
Fax: (203) 837-9049
Student Registration Form
Entering Year: ____________
Semester:
Spring
Spring Break
Summer
Fall
Winter Intersession
Enrollment Status (please check one):
Previously registered
New student
PERSONAL INFORMATION
WCSU Banner ID No. ___ ___ ___ ___ ___ ___ ___ ___
Social Security No. ___ ___ ___ – ___ ___ – ___ ___ ___ ___
Social Security number is not required; optional only for tax purposes.
Gender:
Male
Female
Race:
American Indian
Asian
Black (Not of Hispanic Origin)
Hispanic
White
Other
Prefix:
Mr.
Mrs.
Miss
Ms.
Dr.
Name:
_____________________________________________________________________________________________________________________________
LAST
FIRST
MI
Address: ____________________________________________________________________________________________________________________________
NUMBER & STREET
APT OR UNIT
_____________________________________________________________________________________________________________________________________
CITY/TOWN
STATE
ZIP
Phone:
_____________________________________________________________________________________________________________________________
HOME
MOBILE
Email Address:
_______________________________________________________________________________________________________________________
Emergency Contact: ___________________________________________________________________________________________________________________
NAME/RELATIONSHIP
PHONE
Date of Birth: ____________________
Veteran Status:
Yes
No
If yes, have you been in contact with the Office of Veterans Affairs?
Yes
No
Are you a Connecticut resident?
Yes
No
Are you a citizen of the United States?
Yes
No
Educational level to date:
High school diploma or equivalent
A.S. degree
Bachelors degree
Master’s degree
Doctoral degree
COURSE INFORMATION
I would like to register for the following courses (proof of prerequisites required with proper documentation (i.e. SAT/ACT scores, unofficial transcript, etc.):
5-DIGIT COURSE CODE
DEPARTMENT
COURSE NO.
SECTION
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
PAYMENT INFORMATION
1.
All payments are due at the time of registration. WCSU accepts cash, check, debit cards, Discover and MasterCard; Visa and
American Express are not accepted. All credit card transactions (including debit cards) at WCSU will be subject to an additional
2.5% convenience fee. No mailed, faxed or in-person credit card transactions will be processed. Credit card payments may only
be made online, securely at wcsu.edu/ezpay.
2.
Course withdrawal policies are available online at wcsu.edu/registrar. Refund policies are available at wcsu.edu/cashiers.
Please note that the registration fee is non-refundable.
3.
Non-payment does not automatically withdraw you from a course nor act as a refund request; you must notify the Registrar’s Office to
be formally withdrawn.
I realize that by registering for these classes I will be held responsible for full payment of the above-listed courses in accordance with the terms
outlined above. Please refer to the Cashier’s office for payment schedule.
________________________________________________________________________________________________________________________
SIGNATURE
DATE
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