Three courses focusing on Autism are available to community professionals seeking to increase their knowledge base.
Social Security #First NameLast Name___________________________ __________________________ __________________________
Address
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City State/Zip E-mail Address
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Home Phone Cell Phone Work Phone
Education Information
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College/University Undergraduate Degree/Major Date Degree Earned GPA
Do you hold licensure or teacher certification? Yes No If yes, list license or certification area/s:
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For Federal Reporting Purposes
Gender:Date of Birth: ______________ Male Female
1. What is your ethnicity? Not Hispanic or Latino Hispanic or Latino
2. What is your race? Mark one or more races to indicate what you consider yourself to be.
White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander
Confirmation of Student Understanding
By signing below, I confirm my understanding that continuation in subsequent courses is dependent on program director approval and satisfactory academic
performance. I also confirm my understanding that I am responsible for tuition costs associated with the course(s) and agree to pay tuition by tuition due
date. I understand that if a college debt must be referred to outside sources for collection, that I will be responsible for paying additional collection costs
including but not limited to, reasonable attorney fees and disbursements.
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Printed Name Signature Date
OFFICE USE ONLY
Requirements for non-matriculation approval (to be completed by approved college designee for program of interest):
Provision Met
Completion of undergraduate degree Yes No
Background commensurate with course material Yes No
Approval Granted by Program Director Yes No (Note – if approval has been granted, please select one course below for registration)
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AUT 660*CE AUT 660*30 Fall (list year)
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AUT 661*CE AUT 661*30 Spring (list year )
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AUT 662*CE AUT 662*30 Summer A (list year)
Note – A new approval form will be required for each semester of enrollment.
Approval by Program Director:
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Printed Name Signature Date
Dr. Shanna Jamanis, Nazareth College ORTo obtain approval, Dr. Dawn Vogler-Elias -- --
send form to one of Communication Sciences and Disorders Inclusive Education Programs
the program directors: Nazareth College Nazareth College
4245 East Ave., Rochester, NY 14618 4245 East Ave., Rochester, NY 14618
585-389-2770 • dvogler9@naz.edu 585-389-2622 • sjamani9@naz.edu
UTISM
OURSE
EQUENCE
PPROVAL
ORM
Program Director approval required; approved forms will be processed by Registrar’s Office, Smyth Hall 1
Phone: (585) 389-2819 Fax: (585) 389-2612 Email: registrar@naz.edu
Non-credit: 0 credit pass/fail option is available for ½ the
tuition rate. 2020-2021 rate is $1185 plus $25 registration fee.
**Tuition increase applied annually, effective Summer A.
Credit bearing: Students can earn 3 credits and receive a grade.
2020-2021 tuition is $2495 (includes all fees).
**Tuition increase applied annually, effective Summer A.
0 Credit Version (Pass/Fail)
3 Credit Version (Graded)
