REGISTRATION REQUEST FORM
CONSORTIUM FOR ONLINE HUMANITIES INSTRUCTION
For the complete set of CIC Consortium requirements, please see your home institution’s Registrar
SECTION 1: GENERAL INFORMATION
HOME INSTITUTION: ____________________________
HOME STUDENT ID: _____________ SSN LAST 4: _____________ BIRTH DATE (MM/DD/YY): _____________
LAST NAME: ____________________________ FIRST NAME: __________________________ MIDDLE INITIAL: _______
ADDRESS: _____________________________________________________________________________________________________
STREET ADDRESS APT/BOX #
__________________________________________ _______________ __________________________
CITY STATE ZIP CODE
TELEPHONE: ___________________________________ EMAIL ADDRESS: _______________________________________
(Institutional address preferred; e.g., name@homecollege.edu)
CITIZENSHIP STATUS: ☐ U.S. Citizen ☐ Permanent Resident ☐ Non-Resident Alien ☐ Asylee/Refugee
GENDER: ☐ Male ☐ Female RACE: ☐ Hispanic ☐ Non-Hispanic
Choose all of the following groups in which you consider yourself to be a member:
☐ American Indian or Native American ☐ Asian ☐ Black or African American ☐ Native Hawaiian or Other Pacific Islander ☐ White
SECTION 2: REGISTRATION INFORMATION
HOST INSTITUTION: ____________________________ Have you previously attended the Host Institution? ☐ Yes ☐ No
COURSE INFORMATION:
FIRST CHOICE: Dept Course Title Course # Section Credits/Units
SECOND CHOICE: Dept Course Title Course # Section Credits/Units
SECTION 3: SIGNATURES
STUDENT: _____________________________________________________DATE____________
**Please return this form to the Registrar’s office at your home institution to complete the registration process. You will
receive a confirmation from the host institution if you have been approved or if the course is not available.**
FOR INTERNAL USE ONLY:
HOME REGISTRAR OR DEAN: ________________________________________ DATE____________
Date Form Rec’d: _______________ Date Form Processed: _______________
HOST REGISTRAR OR DEAN: _________________________________________ DATE____________
Date Form Rec’d: _______________ Date Form Processed: _______________ Approved Not Available
Note: Students who cross-register must follow the academic policies and academic calendar of the institution offering
the course. Students must abide by the college/university catalog or bulletin and course syllabi for courses offered at
another institution.
ICCA
Iowa Catholic Colleges Association
By completing this course registration form, I authorize the teaching institution to send my grades to my home institution.
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