If you have

a disability

requiring special

accommodation,

please call

206/281-2272.

SPIRAL REGISTRATION FORM

USE THIS FORM ONLY FOR COURSES THAT PROVIDE A “CRN” IN THE COURSE DESCRIPTION.

PLEASE NOTE THE FOLLOWING INSTRUCTIONS:

1. Select the payment option and enclose your payment (the cardholder’s signature is required if

paying by credit card).

2. Read and sign the contractual agreement in step four of the registration form.

3. Complete this registration form only if you have been directed to do so in this bulletin. Many

courses require registration to occur on site at the first class session.

MAIL TO:

Seattle Pacific University

School of Education

Continuing Education

3307 Third Avenue West, Suite 209

Seattle, WA 98119-1950

FAX TO:

206/281-2271

QUESTIONS:

800/482-3848

www.spu.edu/spiral

STEP 3:

CONTRACTUAL AGREEMENT.

I request registration in the courses indicated. I have read and agree to the contractual statement and refund policy on the reverse side, which

outlines my obligations to the University.

Signature

Date

SOE

Initials:

Date:

SAS

Initials:

Date:

FOR OFFICE USE ONLY.

Student is responsible

for charges until P.O. is

processed (see back

of form).

?

STEP 1:

PLEASE PRINT, USING BLACK OR BLUE INK.

Quarter

Year

SSN or SPU ID Number (Required for IRS reporting purposes)

Last Name

First

Middle

Former

Permanent Address

Street

City

State

Zip

Mailing Address

Street

City

State

Zip

()

()

Email Address (Required for online courses)

Work Phone

Home Phone

This is my first course through SPU

❑

Yes

❑

No

Gender (Optional):

Ethnicity (Optional):

Required Information:

Birth Date (mm/dd/yy)

❑

Male

❑

African American

❑

Asian American

❑

Hispanic American

❑

U.S. Citizen

❑

Female

❑

Alaskan Native

❑

Caucasian/White

❑

Other

❑

Non-U.S. Citizen

❑

American Indian

❑

Hawaiian

Country:

STEP 2:

COURSE SELECTION.

(If applicable)

Subject

Course

Credits/

CRN

Code

Number

Course Title

Units

Instructor

Begins

Ends

Tuition

Total Credits:

Total Tuition:

2392

EDU

5XXX

Sample Class

3

Smith

9/1/05

10/30/05 $XXX

Optional; however, required

for Web services.

STEP 4:

PAYMENT METHODS.

Payment Options:

Choose one of the following payment methods (A–C). Refer to the

Financial Information

section. Pay only tuition; Do not

include materials and course fees.

❑

A. Check:

Check enclosed for full amount of $

(Make all checks payable to SPU; Do not send cash.)

❑

B. Purchase Order:

Number

Name of School, District or Organization

Organization Address

❑

C. Credit Card:

❑

Visa

❑

MasterCard

Account Number

Expiration Date

Charge full amount of $

to my credit card.

Cardholder Name (Please print)

Cardholder Signature

Cardholder Zip Code

SPU accepts Visa

or MasterCard.

---

OFFICIAL REGISTRATION CONTRACTUAL STATEMENT

I understand and agree that when I register, I have obligated myself to pay for the courses and all other charges

related to this registration. If registering by bank card, I authorize SPU to charge my account the amount noted. If

I default, I agree to pay all costs and expenses incurred by the University in the collection of any sums due under

this registration, including, but not limited to, reasonable attorney’s fees, collection cost and court costs. If these

registration fees are sent out for collection by an outside collection agency or debt collector, the University may

add a collection fee of at least one-third (1/3) and as much as double the principal and interest due on the note and

may disclose my default and other relevant information to credit bureau organizations. This note shall be governed

by the laws of the state of Washington.

If I decide to cancel my registration, I will do so in writing to Student Academic Services. As specified in

Spiral,

I understand that the date I officially withdraw will determine the amount of refund, if any, I will receive.

I understand SPU policy states that admitted undergraduate and post-baccalaureate students may take no more

than 18 credits per quarter; admitted graduate students may take no more than 15 credits per quarter; and that

non-admitted students may take no more than 20 credits per quarter. I also understand that these include all credits

taken at other institutions, and that any credits taken in excess of these limits will be disallowed.

I understand SPU’s academic and graduation requirements as they apply to me, and I assume responsibility

for the selection of the course(s) listed.

These and other matters are covered in detail in

Spiral,

the

SPU Undergraduate Catalog

and the

SPU Graduate

Catalog,

copies of which are available free of charge from Admissions, 206/281-2021 or 800/336-3344.

PURCHASE ORDER REGISTRATION

If your registration will be paid by a purchase order, you can register by

1. Submitting your registration form to the agency who will be paying the purchase order. That agency will submit

all registrations with their purchase order to Seattle Pacific University; or,

2. Mailing in your registration with the purchase order number and district or agency name and complete mailing

address clearly indicated in the purchase order section of the registration form. The purchase order must list

students’ names and social security numbers. If a purchase order is not submitted or does not include the correct

information, students will be responsible for all charges and will begin receiving monthly statements including

late fees.

Please note that a student must choose one of these options, but should check with the agency submitting the

purchase order to determine which one to use.

STUDENT RECORDS AND

CONFIDENTIALITY: FERPA

POLICY

Family Education Rights and Privacy

Act, 1974 (FERPA):

Certain items of

information about individual students are

fundamental to the educational process

and must be recorded. This recorded

data concerning students is used only

for clearly defined purposes and is safe-

guarded and controlled to avoid violations

of personal privacy.

SPU has the responsibility to effectively

supervise any access to and/or release of

official information about its students. In

this regard, the University is committed to

protecting the right of privacy of all indi-

viduals about whom it holds information,

records and files. Access to such records

is restricted to the student concerned, to

parents of a dependent student, to others

with the student’s written consent, to

officials within the University, and to a

court of competent legal jurisdiction.

A complete copy of SPU’s FERPA state-

ment can be found on the SPU home page

at www.spu.edu/depts/sas/ferpa.html or

obtained by contacting the Office of Stu-

dent Life or Student Academic Services.