CHANGE OF REGISTRATION
Name: _______________________________________________________
Student ID: ___________________________________________________
Contact # or Email: ____________________________________________
Are you a Student Athlete? Yes
Are you using Veteran benefits? Yes
DROP/WITHDRAW Course(s) ADD Course(s)
Student’s signature &
date are required for all changes to be processed. Academic advisor signature & date is required for all courses being added.
____________________________________________________________________________________________________________________________________
Student’s Signature Date (MM/DD/YYYY)
_____________________________________________ ______________________________________________________ _________________________________
Academic Advisor’s Signature Printed Name Date (MM/DD/YYYY)
_____________________________________________ ______________________________________________________ _________________________________
Instructor’s Signature Printed Name Date (MM/DD/YYYY)
(Required at the start of the Second Week of Session)
_____________________________________________ ______________________________________________________ _________________________________
Department Chair Signature Printed Name Date (MM/DD/YYYY)
(Required at the start of the Second Week of Session)
Financial Aid Students
Financial Aid Counselor’s signature, printed name, & date is required if your registration status changes from full-time to part-time
________________________________________________ ___________________________________________________ _________________________________
Financial Aid Counselor’s Signature Printed Name Date (MM/DD/YYYY)
Veteran Students (including dependents using VA benefits)
VA School certifying official’s signature, printed name, & date is required for registration changes.
__________________________________________________ _________________________________________________ _________________________________
VA School Certifying Official’s Signature Printed Name Date (MM/DD/YYYY)
International Students
Student’s on a F1 or J1 status must obtain an International student advisor’s signature, printed name, & date.
____________________________________________________________________________________________________________________________________
International Student Advisor’s Signature Printed Name Date (MM/DD/YYYY)
Student Athletes
Athletics Department Representative’s signature, printed name, & date is required if the registration status changes from full-time to part-time.
____________________________________________________________________________________________________________________________________
Athletics Representative Signature Printed Name Date (MM/DD/YYYY)
Registration Agreement: I have read and will abide by all Roosevelt University polices and regulations, including the withdrawal/refund policies. I am responsible for all charges
incurred by this registration. I also acknowledge that my registration will be cancelled if I am suspended and I may not attend class(es) unless officially registered. I understand that if I
default in making full payments to my account that my account may be placed for collections. Upon placement, I will be responsible for paying all collection fees incurred by the
University as a result of pursuing any unpaid balance. The collection agency fee is based on a percentage of my balance, not to exceed 35% of the account balance. In the event my account
is turned over to an outside collections agency, it will have a negative impact on my credit report.
Please return the completed form in person, by e-mail, mail or by fax to either (Digital pictures of the form are not acceptable):
Office of the Registrar, Chicago: 425 S. Wabash Ave., 1M14 Chicago, IL 60605, Phone: (312) 341-3535 fax: (312) 341-3660, Email: registrar@roosevelt.edu or First Stop,
Schaumburg: 1400 N. Roosevelt Blvd., Schaumburg, IL 60173, Rm. 125, Phone: (847) 619-7950, Fax: (847) 619-7922
