Keystone College

Visiting students requesting to take courses at Keystone College should complete this form.

First Name:

Middle Name:

Last Name:

Social Security Number:

Date of Birth:

Home Phone:

Street Address:

City:

State:

Zip:

Mobile:

Email:

With which race do you identify? (check all that apply)

Do you identify as Hispanic or Latino? 

*You will receive notification of your Keystone College network credentials to this email address 30 days prior to the start of classes.

Are you currently enrolled at an institution other than Keystone College in a degree/certificate program?

Are you interested in pursuing a degree at Keystone College? 

Intended Major:

Select a course from the drop down menu to view the meeting days and times.

Term:

How many courses do you wish to enroll in ?

Please indicate your choice of courses:

Course:

Title:

Days:

Beginning Time:

Ending Time:

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Beginning Time:

Ending Time:

Beginning Date:

Ending Date:

Please indicate your choice of courses:

Course:

Title:

Days:

Beginning Time:

Ending Time:

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Beginning Time:

Ending Time:

Beginning Date:

Ending Date:

Please indicate your choice of courses:

Course:

Title:

Days:

Beginning Time:

Ending Time:

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Beginning Time:

Ending Time:

Beginning Date:

Ending Date:

**Please note that students are able to register for up to 12 credits before making formal application to the College.

Please describe any special circumstances the College should be aware of regarding classroom access or course instruction on a separate sheet of paper to submit with this form.  Appropriate documentation must be received by the College at least two (2) weeks prior to the start of your intended term.

Have you ever been convicted of a misdemeanor, felony, or other crime? 

Please explain:

I understand that I am solely responsible for all charges and fees resulting from registration for the course(s) above.  I am aware that the refund schedule for these charges and fees is available at https://www.keystone.edu/admissions/tuition-aid/refunds-and-withdrawals/

I understand that I may be subject to disciplinary action, including admission revocation or expulsion or denial of future admission, should the information I certified above be false.

Student Signature:

Date:

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Registrar’s Office ¦ One College Green ¦ P.O. Box 50 ¦ La Plume, PA 18440-0200 ¦ (570) 945-8224 ¦ registrar@keystone.edu

Keystone College is committed to providing equal educational and employment opportunities without regard to an individual’s sex, race, religion, national or ethnic origin, pregnancy, age, marital status, sexual orientation, disability, or status as a veteran. Keystone College’s commitment is to provide an environment where all students and employees can work and study free from discrimination including sexual harassment, sexual violence and sexual assault. The College policy is in accordance with state and federal laws and executive orders including but not limited to:  Title VI, VII of the Civil Rights Act of 1964, Title IX of the Educational Amendments of 1972, and the Americans with Disabilities Act of 1990. Visit www.keystone.edu/title-ix for additional information.

Copyright c 10/2015 Keystone College                                                                                                                                                                                                                             Rev. 02.21.18

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