Combined Program Course Registration Form
Student ID Number: _____________________________ Term: ___________________________
Last Name: _______________________________ First Name: ____________________________
Table 1: Graduate Courses
Graduate Course Code
Current Undergraduate Major: _____________________________________________________________
Planned Graduate Program: _______________________________________________________
Graduate Program Director Approval: _______________________________________________
By registering for class(es) and signing below you agree to be bound by the terms and
conditions on the second side of this form. You must submit an application for admission to
the above mentioned graduate program as soon as possible:
Student Signature: ________________________________________ Date: __________________
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Payment of Fees/Promise to Pay
I understand that when I register for any class at Sacred Heart University or receive any service
from Sacred Heart University I accept full responsibility to pay all tuition, fees, and other
associated costs assessed as a result of my registration and/or receipt of services. I further
understand and agree that my registration and acceptance of these terms constitutes a
promissory note agreement (i.e., a financial obligation in the form of an educational loan as
defined by the U.S. Bankruptcy Code at 11 U.S.C. §523(a)(8)) in which Sacred Heart University is
providing me educational services, deferring some or all of my payment obligation for those
services, and I promise to pay for all assessed tuition, fees, and other associated costs by the
published or assigned due date. I understand and agree that if I drop or withdraw from some or
all of the classes for which I register, I will be responsible for paying all or a portion of tuition and
fees in accordance with the published tuition refund schedule at Sacred Heart University's
Withdrawal Refund Policy webpage. I have read the terms and conditions of the published tuition
refund schedule and understand those terms are incorporated herein by reference. I further
understand that my failure to attend class or receive a bill does not absolve me of my financial
responsibility as described above.
Delinquent Account/Collection: Financial Hold
I understand and agree that if I fail to pay my student account bill or any monies due and owing
Sacred Heart University by the scheduled due date, Sacred Heart University will place a financial
hold on my student account, preventing me from registering for future classes, requesting
transcripts, or receiving my diploma.
Late Payment Charge
I understand and agree that if I fail to pay my student account bill or any monies due and owing
Sacred Heart University by the scheduled due date, Sacred Heart University will assess late
payment and/or finance charges at the rate of .75% per month (annual rate of 9%) on the past
due portion of my student account until my past due account is paid in full. Such interest to be
computed from the original due date.
Collection Agency Fees
I understand and accept that if I fail to pay my student account bill or any monies due and owing
Sacred Heart University by the scheduled due date, and fail to make acceptable payment
arrangements to bring my account current, Sacred Heart University may refer my delinquent
account to a collection agency. I further understand that if Sacred Heart University refers my
student account balance to a third party for collection, a collection fee will be assessed and will be
due in full at the time of the referral to the third party. The collection fee will be calculated at the
maximum amount permitted by applicable law, but not to exceed 15% of the amount
outstanding. For purposes of this provision, the third party may be a debt collection company or
an attorney. If a lawsuit is filed to recover an outstanding balance, I shall also be responsible for
any costs associated with the lawsuit such as court costs or other applicable costs. Finally, I
understand that my delinquent account may be reported to one or more of the national credit
Communication: Method of Communication
I understand and agree that Sacred Heart University uses e-mail as an official method of
communication with me, and that therefore I am responsible for reading the e-mails I receive
from Sacred Heart University on a timely basis.
I authorize Sacred Heart University and its agents and contractors to contact me at my current
and any future cellular phone number(s), e-mail address(es), or wireless device(s) regarding my
delinquent student account(s)/loan(s), any other debt I owe to Sacred Heart University, or to
receive general information from Sacred Heart University. I authorize Sacred Heart University
and its agents and contractors to use automated telephone dialing equipment, artificial or
prerecorded voice or text messages, and personal calls and e-mails, in their efforts to contact
me. Furthermore, I understand that I may withdraw my consent to call my cellular telephone
using automated telephone dialing equipment by submitting my request in writing to
{Institutional office or position} or in writing to the applicable contractor or agent contacting me
on behalf of Sacred Heart University.
Updating Contact Information
I understand and agree that I am responsible for keeping Sacred Heart University records up-to-
date with my current physical addresses, email addresses, and phone numbers by following the
Office of the Registrar procedure. Upon leaving Sacred Heart University for any reason, it is my
responsibility to provide Sacred Heart University with updated contact information for purposes
of continued communication regarding any amounts that remain due and owing to Sacred Heart
Student Consent and Release for Lecture Capture
In consideration of the benefits conferred on me through my participation in courses at Sacred
Heart University and for other good and valuable consideration, the receipt of which is hereby
acknowledged, I, the undersigned student, hereby grant to Sacred Heart University and its
designees (SHU) the non-exclusive, royalty-free, worldwide, perpetual right, license and
permission to use my name, likeness, voice, biographical information, and image in any and all
audio-visual recordings and other media (whether the media is now known or hereafter
developed) produced by or on behalf of SHU (the Media), solely for educational purposes. I
acknowledge and agree that: I will not receive any compensation of any kind related to this
consent and release; I waive any right to inspect or approve the Media; SHU may use the Media
in any manner, including without limitation, reproducing the Media or creating derivative works
of the Media; I waive any right, title and interest that I may have in the Media; I will view the
Media solely for my own educational purposes in connection with the above-identified course; I
will not make any other uses of the Media, including without limitation, reproducing or
distributing the Media, or providing others with access to the Media; and, only to the extent
permitted by applicable laws, rules and regulations, I release SHU and its personnel from all
liability arising from or related to the Media, and this consent and release.
Entire Agreement
This agreement supersedes all prior understandings, representations, negotiations, and
correspondence between me and Sacred Heart University, constitutes the entire agreement
between the parties with respect to the matters described, and shall not be modified or affected
by any course of dealing or course of performance. This agreement may be modified by Sacred
Heart University if the modification is signed by me. Any modification is specifically limited to
those policies and/or terms addressed in the modification.