Fillable Registration Form Semester (Check One): Spring Summer Fall (Ilisagvik College)

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Registration Form Semester (Check One): Spring Summer Fall (Ilisagvik College)

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  • 4 signatures
  • 33 check-boxes
  • 85 other fields

Country of origin: US
File type: PDF

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Registration Form
Release Information: The Family Educational Rights and Privacy Act protects a student’s right to privacy by limiting information that can be released to the public in what is
referred to as Directory Information. Directory Information is that part of an education record of a student that would not generally be considered harmful or an invasion of
privacy if disclosed. Directory Information can NEVER include: student identification number, race, social security number, ethnicity, nationality, gender. DIRECTORY
INFORMATION is information that can be released to the public without permission from the student. Directory Information at Iḷisaġvik College includes: student's name, local
address, permanent address, email address, photos, and telephone numbers (including cell phone numbers), names and dates of previous high schools and colleges attended,
classification (Freshman, Sophomore), enrollment status, major field of study, dates of attendance and anticipated date of graduation, participation in officially recognized
activities, degrees and awards granted. (Photo maybe used for promotional or reporting purposes.) If you DO NOT want this information released, see the Registration Office
for the Opt Out form.
Office of the Registrar
P.O. Box 749
Barrow, AK 99723
Phone: (907) 852-1757 or 1763
Fax: (907) 852-1784
Semester (Check One): Spring Summer Fall Year 20__
Degree: Non-Degree Degree/Certificate Dual Credit Social Security # (For NEW STUDENTS) or Student Number
PERSONAL INFORMATION
Name: ________________________________________________ Address: _______________________________________________
(Last, First, Middle) (Street/PO Box, City, State, Zip Code)
Date of Birth: __________________ Gender: Male Female Other Email:____________________________________________
Work Phone: _______________________ Cell Phone: __________________________ Home Phone: ______________________________
Ethnicity: (CHECK ONE): Alaska Native American Indian African American Asian
Caucasian Hawaiian Hispanic Pacific Islander Other
Active Military? Yes No If no, Veteran? Yes No US Citizen? Yes No If no, Nation of citizenship: ____________
Permanent Resident? Yes No
BILLING: Please fill this out if the billing is not going to you.
Financial Aid Employer- Funded Company:________________ Grant Funded: # _______________ Iḷisaġvik College
Other: ___________________ Contact Person:_____________________________ Address or Phone #:__________________________
CHECK ANY THAT APPLY: Corporation/Tribe* NSBSD Teacher** Emergency Personnel ** Senior (62 Years+) **
*Please provide Registrar’s Office with a copy **Please submit a tuition waiver form
HOW DID YOU HEAR ABOUT THESE CLASSES? E-mail Facebook KBRW Radio Fliers Ads
Recruiter Website Word of Mouth Other : _____________________________________
Dept
Course #
Sec #
Course Title
Dates / Days / Times
Audit
Instructor
Total credits
Tuition:
$
Registration Fee:
$
Student Support Service Fee:
$
Course, Lab & Materials Fee:
$
Other:
$
TOTAL TUITION & FEES =
$
Student Signature (Required)
Date
Advisor Signature (Instructor) (Required)
Date
Business Office Signature
Date
Registration Office Signature
Date
* Initial Here: _______ I acknowledge that by initialing, I will be fully responsible for costs not covered by Financial Aid, employers, grants or scholarships.
Cost per credit hour: _________
0
$165
0
170
120 Full time
50
click to sign
signature
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1
Tuition Waiver 2019-2020
(1) Select one waiver (one color) you wish to apply for.
(2) Read, agree, and initial each item under that waiver.
Student Name (Last, First, Middle) Date Last 4 digits of SSN
Initial
BOARD OF TRUSTEES TUITION WAIVER
I have been a North Slope Borough resident for at least 30 days and am 18 years or older.
I intend to apply/have applied to a program of study at Iḷisaġvik College. (For continued eligibility, students
must be admitted to a program of study.)
I submitted at least one scholarship application.
Scholarship applied for:
I authorize the IC Registrar’s Office to release grades to the Business Office.
I understand that (1) I must pass 2/3 of the credits I enroll in and (2) achieve a grade point average of 2.0
(Grade C) for the current semester in order to remain eligible for the waiver in future semesters.
Initial
ALASKA NATIVE/AMERICAN INDIAN, OFF-SLOPE TUITION WAIVER
I am Alaska Native/American Indian, do not permanently reside on the North Slope, and am 18 years or older.
I will provide the Registrar’s Office with a copy of my tribal card.
I intend to apply/have applied to a program of study at Iḷisaġvik College. (For continued eligibility, students
must be admitted to a program of study.)
I submitted at least one scholarship application.
Scholarship applied for:
I authorize the IC Registrar’s Office to release grades to the Business Office.
I understand that (1) I must pass 2/3 of the credits I enroll in and (2) achieve a grade point average of 2.0
(Grade C) for the current semester in order to remain eligible for the waiver in future semesters.
Initial
NORTH SLOPE BOROUGH SCHOOL DISTRICT TUITION WAIVER
I am a certified teacher for the NSBSD.
I understand that this waiver applies only to DEED courses eligible for certification or any course with an
ANS/INU designator.
Initial
NORTH SLOPE FIRE DEPARTMENT TUITION WAIVER
I am an employee or volunteer firefighter/EMS personnel for the NSBFD.
I intend to apply/have applied to a program of study at Iḷisaġvik College. (For continued eligibility, students
must be admitted to a program of study.)
I authorize the IC Registrar’s Office to release grades to the Business Office.
Initial
IḶISAĠVIK EMPLOYEE/SPOUSE/DEPENDENT WAIVER
My name is ________________________________________, and I am a permanent Iḷisaġvik employee.
I authorize verification of my employment status.
I authorize my spouse/dependent __________________________________ to register under this waiver.
I understand that any coursework under this waiver must be completed with a grade of “C” or higher.
I acknowledge that if I and/or my eligible spouse/dependent do not earn a grade of “C” or higher, I am
responsible for the cost of tuition and authorize an immediate payroll deduction in the amount owed for
courses taken under this waiver.
I authorize the IC Registrar’s Office to release grades to the Business Office.
Initial
NORTH SLOPE BOROUGH ELDER WAIVER
I am a North Slope Borough resident.
I am at least 62 years of age.
Questions about this form? Contact Registration at 852-1757 or Admissions at 852-1754
2
Course Information (Waiver cannot be applied to repeat classes)
This waiver applies to the following semester (Select one):
Summer 2019 Deadline: July 1, 2019
Fall 2019 Deadline: October 1, 2019
Spring 2020 Deadline: March 1, 2020
Vocational Education/Workforce Development Short-term Training (Mark if applicable)
Student Agreement and Signature
By signing below, I confirm that the information I have provided is true and correct. I understand and agree to
the following:
This is a waiver of tuition. Registration fees, lab fees, lab kits, art supplies, textbooks and other special
costs are my responsibility.
Tuition waivers cannot be applied retroactively and will not be issued if my student account has an
outstanding balance of $500 or higher.
If I do not pass 2/3 of my credits and do not achieve a GPA of 2.0 (“C”) in this current semester, I will
not receive a waiver for the next semester I take classes. Instead, I am responsible for the cost
(personally and/or through scholarships or federal financial aid). However, after one successful semester
of taking classes without utilizing the tuition waiver, I can apply for a waiver again.
I give Iḷisaġvik College permission to use my name and image in marketing materials related to the
Tuition Waiver program.
Student Signature Date
Iḷisaġvik College Employee Signature (for IC Employee Waiver) Date
Iḷisaġvik College Supervisor Signature (for IC Employee Waiver) Date
Registrar’s Office Verification:
Date:
President Signature Date
Extensions are granted for classes
starting after the deadline.
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Registration Form Semester (Check One): Spring Summer Fall (Ilisagvik College)

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Completed 25 July 2020

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