Check all that apply
Fall
Summer
Spring
Year
East Central College
1964 Prairie Dell Road, Union, MO 63084 636-584-6500 -
www
.
eastcentral
.
edu
Registration Form
(Submit signed form to Registration Office, or use online registration on your eCentral account.)
All forms must be printed or typed in black or blue ink. (Penciled forms will not be accepted)
Student ID #: ______________________________________________________________
Advisor: ___________________________________________________________
Last Name ______________________________
First Name _________________
Former Names ___________________________________
Street No./Route/PO Box _____________________________________________
City________________________
Is this a new address? Yes No
Street No./Route/PO Box_____________________________________________
City________________________
Is this a new address? Yes No
Home Phone (____) ______________________________
Cell Phone (____) _________________________________
Work Phone (____) ______________________________
Email Address: _________________________________
Birthdate: ____/____/_______________
Marital Status: Single Married Other
Academic Program: _________________________________________________________________________________
Do you plan to graduate at the end of this term? Yes No Are you a veteran? Yes No
Public school district in which you reside:
Crawford County R-1 (Bourbon) New Haven St. Clair R-13 Sullivan C-2 Union R-11
Washington
Franklin County R-2 Lonedell R-14 Spring Bluff R-15 Strain-Japan R-16 Other (specify district & city) ___________________
Onl
ine Registration
Online Registration is available on your eCentral account.
NOTICE OF NON-DISCRIMINATION – Applicants for admission and employment, students, employees, and sources of referral of applicants for admission and employment are hereby notified that East Central College does not
discriminate on the basis of race, color, religion, national origin, ancestry, gender, age, disability, or veteran status. Inquiries related to employment practices may be directed to Human Resources Director, 005D Multipurpose Building,
telephone number 636-584-6710 or hrnotice@eastcentral.edu. Inquiries/concerns regarding civil rights compliance as it relates to student programs and services may be directed to the Vice President of Student Development,
636-584-6565 or stnotice@eastcentral.edu. Both offices are located at the ECC main campus located at 1964 Prairie Dell Road, Union, MO 63084.
Circle if
Auditing
Course
Total credits this semester
Students enrolled in more than 18 hours (Fall/Spring)/9 hours (Summer) must have the approval of the
Chief Academic Officer (Vice President of Instruction) or the Chief Student Affairs Officer (Vice President
of Student Development
