Mail this form with a check or money order made payable to CSM to: COLLEGE OF SOUTHERN MARYLAND, CONT ED (REG), PO BOX 910, LA PLATA MD 20646-0910. CHECK OR
MONEY ORDER MUST ACCOMPANY THIS REGISTRATION. You may also register in person or through the college’s online services.
STUDENT’S SOCIAL SECURITY NUMBER* or STUDENT ID # YEAR
(*Providing a social security number in connection with a continuing education course is voluntary, unless enrollment is pursuant to the Workforce Investment Act or as otherwise required by law.)
LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH (month/day/year)(required)
FORMER NAME
HOME ADDRESS
CITY COUNTY STATE ZIP CODE
DAY TELEPHONE ((area code) number) EXT. EVENING TELEPHONE ((area code) number) EXT.
EMERGENCY CONTACT PERSON EMERGENCY TELEPHONE ((area code) number)
E-MAIL ADDRESS
The College of Southern Maryland collects information on our students’ birth date, gender, ethnicity and citizenship which is used for reporting purposes only in compliance with the Maryland Higher Education Commission
and U.S. Department of Education.
GENDER: MALE FEMALE
ARE YOU OF HISPANIC OR LATINO ORIGIN? YES NO
WHAT IS YOUR RACE? SELECT ONE OR MORE. WHITE BLACK OR AFRICAN AMERICAN ASIAN
AMERICAN INDIAN OR ALASKAN NATIVE NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
RESIDENCY: CALVERT COUNTY CHARLES COUNTY ST. MARY’S COUNTY
OTHER MD COUNTY OUT OF STATE
ARE YOU A U.S. CITIZEN? YES, I AM A U.S. CITIZEN/U.S. NATIONAL
NO, BUT I AM AN ELIGIBLE NONCITIZEN
TYPE ALIEN REGISTRATION NUMBER
NO, I AM NOT A U.S. CITIZEN NOR AN
ELIGIBLE NONCITIZEN
IMMIGRATION VISA TYPE IMMIGRATION VISA NUMBER
CONTINUING EDUCATION CERTIFICATE PROGRAM (IF APPLICABLE): _____________________________________________________
The information I have provided above is accurate. I understand that I am financially responsible for all charges that I incur at CSM and that the Student Code of Conduct (available from the Student Life Department) applies to all CSM students. I will follow all of the college’s policies and procedures. When
registering for WFS or youth courses, I understand that I (or my parent or guardian if I am less than 18 years old) will be required to sign a Statement of Informed Consent, Assumption of Risk and Release Form, and/or a health status questionnaire prior to my (or my child’s) participation in the activity. Based
upon the results of the health status questionnaire, a medical release may be required prior to participation. I also understand that, in the event of an emergency, the college will contact emergency services to arrange transport for me (or my child) to a nearby health-care facility.
SIGNATURE OF APPLICANT DATE (month/day/year) SIGNATURE OF PARENT OR GUARDIAN DATE (month/day/year)
(IF APPLICANT IS UNDER 18 YEARS OF AGE)
PAYMENT MUST ACCOMPANY THIS REGISTRATION!
TOTAL
*RESIDENCY FEE: Maryland residents living outside of Charles, Calvert, and St. Mary’s counties—
add $5.00 under residency fee, out-of-state residentsadd $10.00 under residency fee.
SUBJECT COURSE NO. SECTION NO. COURSE TITLE BEGIN DATE COURSE RESIDENCY COURSE TOTAL
TUITION FEE* FEE
CSM Continuing Education Registration Form
Statement for prospective students: The College of Southern Maryland makes several federally required reports and statistics available for prospective students. The Campus Public Safety Report contains college policies regarding a variety of safety and security issues and includes crime statistics for the
college. This report is available at ready.csmd.edu. The college also maintains a report addressing participation rates by students in intercollegiate athletics, coaching staffs, and certain expenses associated with intercollegiate athletic teams. Both reports may also be obtained by contacting the Registrar’s
Office, located in the AD Building on the La Plata Campus and at 301-934-7588.
NONDISCRIMINATION POLICY
The College of Southern Maryland does not discriminate on the basis of race, color, national origin, gender, disability, age, sexual orientation, religion, or marital status in its programs or activities. The academic support/ADA coordinator, Disability Support Services—La Plata Campus,
Learning Resource Center (LR Building), Room 123, 301-934-7614—has been designated to handle inquiries regarding discrimination on the basis of disabilities. The associate vice president, Institutional Equity and Diversity Office—La Plata Campus, Campus Center (CC Building),
Room 208A, 301-934-7658—has been designated to handle inquiries regarding discrimination.
ADA STATEMENT
Individuals with disabilities who require special accommodations in order to participate in the college’s instructional programs should notify the academic support/ADA coordinator at 301-934-7614 at least six weeks before the class begins. Requests made after this deadline will
be considered on an individual basis and addressed whenever possible.
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