Mailing
Address City State Zip
Phone ( ) Alt. # ( ) E-Mail
Social Security Number Date of Birth Sex:
Male
Female
Are you a U.S. Citizen?
Yes
No Nationality: WA Resident:
Yes
No Resident Since (MM/YY):
Are you Hispanic in origin?
Yes, I am Hispanic in Origin. (Select one or more): (H10)
No, I am non-Hispanic in origin. (H20)
Colombian (707)
Costa Rican (708)
Cuban (709)
Dominican (710)
Ecuatorian (Ecuadorian) (711)
Guatemalan (716)
Honduran (718)
Mexican or Mexican-
American (Chicano) (722)
Nicaraguan (723)
Panamanian (724)
Peruvian (726)
Puerto Rican (727)
Salvadoran (712)
Spanish (730)
Uraguayan (734) Venezuelan (735)
Other Hispanic Origin (H10):
How do you describe your race? (Select one or more):
American Indian (Select one or more):
Chehalis (020)
Chinook (055)
Colville (159)
Cowlitz (027)
Duwamish (031)
Hoh (052)
Jamestown (023)
Kalispel (156)
Kikillus (032)
Lower Elwha (024)
Lummi (028)
Makah (053)
Muckleshoot (034)
Nisqually (035)
Nooksack (029)
Port Gamble Klallam (025)
Puyallup (036)
Quileute (051)
Quinault (050)
Samish (037)
Sauik-Suiattle (038)
Shoalwater (492)
Skokomish (079)
Snohomish (041)
Snoqualmie (042)
Spokane (160)
Squaxin Island (043)
Steilacoom (044)
Stillaguamish (045)
Suquamish (045)
Swinomish (047)
Tulalip (048)
Upper Skagit (039)
Yakama (078)
Other American Indian (R13): ________________________________________
Alaska Native (Select one or more):
Alaska Aleut (Unangan) (941)
Alaska Alutiiq (942)
Alaska Athabaskan (014)
Alaska Eskimo (Inupiaq or Yupik) (935)
Alaska Eyak (943)
Alaska Haida (016)
Alaska Tlingit (017)
Alaska Tsimshian (018)
Other Alaska Native (950):
Asian (Select one or more):
Asian Indian (600)
Bangladeshi (601)
Bhutanese (602)
Burmese (603)
Cambodian (Kampuchean) (604)
Chinese (605)
Filipino (608)
Hmong (609)
Indonesian (610)
Japanese (611)
Korean (612)
Laotian (613)
Madagascar (639)
Malayan (614)
Maldivian (634)
Mongolian (624)
Nepali (635)
Pakistani (616)
Singaporean (637)
Sri Lankan (617)
Taiwanese (606) Vietnamese (619)
Thai (618) Other Asian (R20):
Black or African American (R30)
Native Hawaiian or Other Paci c Islander (Select one or more):
Fijian (676)
Guamanian (660)
Kosraean (667)
Mariana Islander (661)
Marshall Islander (662)
Micronesian (669)
Native Hawaiian (653)
Palauan (663)
Papua New Guinean (678)
Ponapean (Pohnpeian) (670)
Samoan (655)
Solomon Islander (679)
Tahitian (656)
Tarawa Islander (672)
Tokelauan (659)
Tongan (657)
Trukese (Chuukese) (674)
Vanuatuan (New Hebrides Islander) (680)
Yapese (675)
Other Paci c Islander (R40):
White (includes people of European, Middle Eastern, or North African descent)
(R50)
SPECIAL STUDENT REGISTRATION FORM
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Yes, last quarter attended:
Last School Attended
Name of School City/State
Ending Period (MM/YY) Diploma/Deg
ree
Are you a military veteran?
YES
NO Are you eligible for federal dependent/veteran bene ts?
YES
NO
I understand and accept the registration and payment policies of The Evergreen State College.
Signature Date
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Late fee?
NO
YES $50 $100
Student Accounts
OK to reg?
YES
NO
Financial Aid
Eligibility Review
YES
NO
OFFERING TITLE
FACULTY SIGNATURE
IF REQUIRED OR ADDING AFTER THE QUARTER BEGINS
CRN
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QUARTER
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