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
HAS THE ABOVE INFORMATION CHANGED SINCE THE LAST TIME YOU REGISTERED FOR CLASSES? YES NO
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
IMMIGRATION VISA TYPE
ELIGIBLE NONCITIZEN
IMMIGRATION VISA NUMBER
CONTINUING EDUCATION CERTIFICATE PROGRAM (IF APPLICABLE): _____________________________________________________
The information I have pr
ovided above is accurate. I understand that I am nancially 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. By coming onto a CSM campus, I indicate that I have read, understand, and will comply with the health and
safety rules and requirements outlined at ready.csmd.edu. I assume the inherent risk of exposure and possible infection related to novel coronavirus/COVID-19 by coming to campus.
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 residents—add $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 se
veral 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 Ofce, 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 director of Disability 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 executive director of Student Affairs—La Plata Campus, Administration (AD) Building, Room 220A, 301-539-4746—should be contacted for student discrimination inquiries. Human Resources—La Plata Campus, Campus
Center (CC Building), Room 212, 301-934-7700—should be contacted to handle all other discrimination inquiries.
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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