Term:______________________ Todays Date: ___________________ Student ID: B________________________
Check the box if this is a new address and/or phone number. Please print or type the following information.
Last Name: _______________________________________________ First Name:_____________________________
Middle Name: __________________________________
Address: _______________________________________________________________________________________
City:_____________________________________ State:________________________Zip:_______________________
Phone:____________________________________________ Major:_________________________________________
Student Signature:______________________________________________________________
You must read and consent to the information on the back of this form prior to registration.
ACTION CODE for table below: A = Add, D = Drop, AU = Audit (additional form required).
Code
CRN
Course
Subject
Course
Number
Section Course Title Crd. Days Time
This is a
sample row
00000
ARTC
1300
70C
Drawing 1
3
M,W
3:00 p.m.
*High School Guidance counselor signature is required for course drop.
Counselor Print Name:_____________________________________________________________________________
Signature and Date: _______________________________________________________________________________
INSTRUCTOR/DEPARTMENT CHAIR APPROVAL REQUIRED FOR EXCEPTIONS: Signed form must be provided to
Advising within 1 week of approval or it becomes invalid. My signature represents approval of the following exceptions for
this course:
Pre-requisite waived Course overload on closed classes Late Add
Co- requisite waived Other: Campus Associate Provost Course Reinstatement
Instru
ctor Print Name: _________________________________________________________
Signature/Date: _________________________________________________________
Department Chair Print: ________________________________________________________
Signature/Date: _________________________________________________________
Associate Provost Print:________________________________________________________
Signature/Date: _________________________________________________________
Eastern Florida State College is an equal opportunity/equal access institution.
SCA-003 R092418
Add/Drop Registration Planning Form
REGI
STRATION AND FINANCIAL RESPONSIBILITY AGREEMENT
Tha
nk you for choosing Eastern Florida State College. In addition to all Eastern Florida State College (EFSC) academic standards
and policies, I hereby agree to comply with the terms and conditions specified in this Registration and Financial Responsibility
Agreement in order to enroll for courses at EFSC. I also agree to abide by rules and regulations described in the EFSC Catalog and
EFSC Student Handbook.
I ac
knowledge that any activity I conduct through EFSC indicates my agreement to the specified terms and conditions, including
my agreement to be financially responsible to EFSC for payment of all tuition, fees and related costs of enrollment for classes in
which I am registered whether or not I attend the class.
I un
derstand that course(s) must be dropped before the end of the drop period in order to be eligible for a full refund. It is my
responsibility to drop my classes as the college will not automatically drop them for me.
I ac
knowledge that if I withdraw from a course(s) after the end of the drop period, or if I am administratively withdrawn for non-
attendance or other reasons, I will be responsible for repaying any applicable Bright Futures Scholarship funds, Federal Title IV
financial aid funds, or any other amount due as a result of the withdrawal. Any reduction in financial aid based on nonattendance
will result in a balance due to EFSC.
I un
derstand past due student account balance will result in a financial hold, which prevents future registrations as well as other
services being offered in accordance with college policy. I understand and agree that EFSC will withhold transcripts, diplomas, and
other services until all outstanding balances have been satisfied in full.
I ac
knowledge that all outstanding obligations (along with appropriate personal information including social security number)
may be referred to an outside collection agency and credit reporting bureaus.
I un
derstand that I am responsible to reimburse EFSC the fees of any collection agency, which may be based on a percentage not
to exceed 33% of the debt, including attorney fees and court costs.
In a
ddition, I agree to allow EFSC and its agents to contact me at any cell phone number that I provide now or use in the future,
using automated telephone dialing systems, artificial or pre-recorded voice or text messages, or personal calls regarding my
obligation to repay my debts to the EFSC.
I al
so authorize EFSC or its agents to contact me via my easternflorida.edu address or an email address that I provide to EFSC. I
understand that others may be able to review my messages and/or emails related to my debts sent to or from EFSC including
their contents, which may include information about my debt and its status.
I un
derstand that EFSC uses Titan E-mail, a free student email system, as the official means of communication for registered
students. Financial Services utilizes this system for notifications regarding student accounts. Students should maintain and check
their EFSC e-mail accounts regularly.
I understand this agreement shall be construed in accordance with Florida law, and any lawsuit to collect unpaid fees may be
brought in the appropriate court sitting in Brevard County, Florida, regardless of my domicile at the time of bringing such action.
I understand by signing this form, I am agreeing to all terms and conditions set forth herein above and agree to the incorporation
of any other related documents. I enter into this Registration and Responsibility Agreement with full knowledge of its legal
implications and without coercion and/or promises made to me by the college. I also agree and acknowledge that prior to
agreeing to this Agreement, I have the right and option to discuss the terms and conditions herein with a private attorney at my
sole expense.
Stu
dent Signature: _____________________________________________________ Date:_______________
Student ID Number: B____________________________________
Received by: ____________________________________________ Term:_____________________________
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