DS 120
Office of the Registrar
4/2019
STUDENT NAME: _________________________________________ DATE: ___________ NON-MATRIC MAJOR:__________________________________
S
TUDENT ID NUMBER or SSN: _____________________ Have you attended Daemen Before: □ YES □ NO
I
f yes, are you a □ Alumni Audit □ Senior Citizen Audit or □ Non-Matriculated Status
Are any of the courses selected designated as Service Learning courses: □ YES □ NO. IF YES, consult the Service Learning Office for the appropriate Service
Learning permission form.
TE
RM: CHECK ONE: □ FALL ________
□ I
NTERSEMESTER ________
□ S
PRING ________ □ SUMMER ________
Year Year Year Year
CHECK ONE OR MORE OF THE FOLLOWING AS APPROPRIATE: I am requesting permission to:
□ Enroll in a closed course
□ Waive the course prerequisite and/or corequisite
□ Instructor’s permission is required
□ Other: Please explain: ___________________________________________
REQUIRED SIGNATURES
Please sign the form and secure only the required signature(s)
___________________________________________ ____________ __________________________________________ ____________
Student’s signature Date Instructor’s signature (if applicable) Date
__________________________________________ ____________ __________________________________________ ____________
Department Chair’s signature (if applicable) Date Instructor’s signature (if applicable) Date
(Required for all Graduate Level course work)
__________________________________________
Student Success Center
Date
____________
