Fillable Minnesota State University Senior Citizen Registration Form

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Minnesota State University Senior Citizen Registration Form

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The Minnesota State University Senior Citizen Registration Form form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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______________________________________________________________________________________________________________________________________
Residents of Minnesota, age 62 or over before the beginning of the term may either (a) audit a class free without credit or (b)
receive credit by payment of an administrative fee of $20.00 per credit. The following also applies:
1. A one-time application fee of $20.00 must be paid if you have never attended MSUM.
2. Registration will not be processed until after the second day of class for the semester AND only if space is available after all
tuition paying students are enrolled.
3. Senior citizens will be responsible for the cost of any lab or course fees, regardless of whether credit is earned or not.
Name (Last, First, Middle) Student ID (if known)
Mailing Address (Street and #, City, State and Zip Code)
Home Phone Cell Phone Email Address
Date of Birth (mm/dd/yyyy) Social Security Number (record keeping purposes only)
Ar
e you a US Citizen? Yes _____ No _____ Gender? M _____ F _____ Are you a Minnesota Resident? Yes ____ No ____
Predominant ethnic or racial background- (requested for State and Federal Reporting)
Asian/Pacific Islander _____ Native American _____ Hispanic _____
Black/African American _____ White/Non-Hispanic _____ International Student _____
Are you seeking a degree at MSUM? Yes _____ No _____ Will you be auditing your courses? Yes _______ No _______
Semester you plan to take courses: Fall ______ Spring_______ Summer ________ Year ______________
Pr
oposed Class Schedule:
Subject
Number
Course Title
Course ID
Credits
Total Credits
Senior Citizen Registration Form
Additional Instructions:
Billing Procedure: Bills will NOT be mailed. Students can view and pay bills online on their eServices account or pay at the Business
Services Office in Owens Hall 106. Unpaid bills create a Business Services hold and no further registration will be permitted. Tuition
rates are subject to change. For more information, go to the Business Services website at www.mnstate.edu/business-services or
call 218/477-2221.
Student Data: Specific data items requested on this form are needed to process your registration, to maintain your permanent
academic record, and/or to comply with requirements for periodic summary reports by state, federal, or accrediting agencies.
Information from your individual record may be released to individuals or agencies other than college officials only with your
permission or with specific legal authorization. Failure to provide requested data may result in the delay of registration or record
processing until such time as needed information is supplied.
You may choose to withhold the following information from public use by initializing one or both of the following categories.
However, such information will be withheld in all circumstances, and students are cautioned to consider possible inconveniences.
Once a category has been withheld, it will remain withheld until such time as the student decides to make available either or both
categories of information.
Category I _____ the student’s name, address, telephone number
Category II _____ major and minor fields of study, class level, dates of enrollment, full-time/part-time status, awards, honors
(including Dean’s List), degree(s) conferred (including date), previous education institution(s) and dates attended, e-mail address,
photographs taken and maintained by the University for various purposes, past and present participation in officially recognized
activities and sports, height and weight of athletes, and gender.
S
tudent’s Signature: ________________________________________________________________ Date: _____________________
Return form to:
Minnesota State University Moorhead Registrar’s Office
Owens Hall 210 | 1104 7
th
Ave S | Moorhead MN 56563
Phone: 218.477.2565 Fax: 218.477.2941
Email: Registrar@mnstate.edu
Minnesota State University Moorhead is an equal opportunity educator and employer and is a member of Minnesota State System.
I hereby certify I have provided all information as completely and accurately as possible.
Date: __________________________ Signature: ________________________________________________________________
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Minnesota State University Senior Citizen Registration Form

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Completed 14 April 2020

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