East Central College Updated October 2018 SSC
1964 Prairie Dell Rd, Union, MO 63084 636-584-6588 www.eastcentral.edu
Registration Form
NOTICE OF NON-DISCRIMINATION
Applicants for admission and employment, students, employees, and sources of referral of applicants for admission and employment and individuals with whom the Board of Trustees and college officials do business are hereby notified that East Central
College does not discriminate on the basis of race, color, religion, national origin, ancestry, gender, sexual orientation, age, disability, genetic information or veteran status. Auxiliary aids and services are available upon request to individuals with
disabilities. Inquiries/concerns regarding civil rights compliance as it relates to student programs and services may be directed to Vice President of Student Development, 131 Buescher Hall, telephone number 636-584-6565 or stnotice@eastcentral.edu.
*See back for eCentral instructions.
Student ID: __________________________ First Name: ______________________________ Middle Initial: _____ Last Name: _________________________________________
Birthdate: ______/________/_________ Public School District for address listed below: (specify district & city) ______________________________________________
Address: Street No./Route/PO Box ______________________________________________________City________________________________________ State_____ ZIP__________
Home Phone: ________________________________ Cell Phone: _____________________________ Work Phone: _______________________________________
Email Address: ___________________________________________________________________________________________ Is this new contact information? □Yes □No
Do you plan to graduate at the end of this term? □Yes □No (If yes, please submit a graduation application Priority Deadlines: Spring – Dec. 1; Summer – May 1; Fall – June 15)
MUST BE FILLED OUT IN BLACK/BLUE INK. PENCILED FORMS WILL NOT BE ACCEPTED!
All fields required for each class. TERM: Check all that apply: □ Fall 20___ □ Spring 20___ □ Summer 20___ □ Other _________ 20___
Days & Times
M Tu W Th F Sa Su
Office Use
For Applicable
Signatures
Students enrolled in more than 18 hours (Fall/Spring)/9 hours (Summer)
must have the approval of the VP of Instruction or VP of Student Development
________________________________________________________________________ __________________________________________________________________
Student Signature Date Advisor Signature Date
