Central Connecticut State University Office of the Registrar / Enrollment Center
Independent Study Course Registration Form Undergraduate / Graduate Students
Name: ID:
Street: Telephone No.:
City/State/Zip: Date:
Course Type Academic Term Year Student Class Student Status
□ Independent Study
□ Internship
□ Fall □ Spring
□ Summer □ Intersession
□ Freshman
□ Sophomore
□ Junior
□ Senior
□ Graduate Student
□ Full-Time
□ Part-Time
The sponsoring faculty member completes this section with the student:
Faculty Sponsor:
Course Title:
Course Number (e.g., ART 498, PSY 499):
Number of Credit Hrs. (e.g., 3, 4, 6):
Average Weekly Contact Hrs. (e.g., 3, 4, 6):
Faculty Load Credit:
Meeting Place (classroom, office, or other location):
**Description of Course and Its Relationship to the Student’s Program:
**Evaluation Schedule:
**Planned Readings and Other Assignments:
**Means for Evaluation:
Required Independent Study Course Registration Written Agreement/Approvals:
Submitted by: ______________________________ ______________________________ Date: _________________
Student’s Signature Printed Name
Sponsored by: ______________________________ ______________________________ Date: _________________
Faculty Member’s Signature Printed Name
Approved by: ______________________________ ______________________________ Date: _________________
Department Chair’s Signature Printed Name
______________________________ ______________________________ Date: _________________
Dean of Academic School’s Signature Printed Name
______________________________ ______________________________ Date: _________________
*Dean of Graduate School’s Signature Printed Name
*Required when an independent study or internship course is requested by a graduate student
**If additional space is needed for these sections, please attach a second page
Effective 11/2005. Distribution of Completed Form: Original-Enrollment Center or Registrar’s Office;
copies-faculty member, chair, student, academic dean, Graduate School (if applicable)
