HIGH SCHOOL INDEPENDENT LEARNING REGISTRATION FORM

Photocopies of this form are acceptable. Please Print.

Include payment of $110.00 per course, complete the form and mail to

High School Independent Learning Program, Division of Continuing Education,

University of Colorado, Campus Box 178, Boulder, CO 80309-0178

or Fax Registration Form to (303) 492-3962.


Date ___________________ 	


Name _________________________________	  Soc Sec # ____________________


Sex:    ___ Male     ___ Female	


Selective Service Registration Compliance:

	___ I certify that I am registered with Selective Service

	___ I have not reached my 18th birthday   ___ I am female


Address _________________________________ Day Time Phone ________________	
                   (Street)

________________________________________ Birth Date _______________ 	
(City)          (State)   (Zip)


School Name _____________________________ / _____________________________ 	
                                                        

School Address __________________________________________________________	
                   (Street)          (City)         (State)        (Zip)

_______________________________________________________________________	
Dept. Abbr. & Course No.				Title

_______________________________________________________________________	
Dept. Abbr. & Course No.				Title

_______________________________________________________________________	
Dept. Abbr. & Course No.				Title

_______________________________________________________________________	
Dept. Abbr. & Course No.				Title



* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 

___ I authorize the release of my grades to the school listed below. 



Student Signature ______________________________________


Registration will be returned if the following information is not supplied
(unless the course is taken for no credit). Please type or print:


Supervisor's Name ______________________________ Title ______________________	



Supervisor's Address _______________________________________________________		
                                           (Street)

______________________________________________ Phone ____________________	
   (City)              (State)          (Zip)



Signature below authorizes acceptance of credit recommendation and approval 
of the supervisor:



School Official __________________________________Title _______________________



* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 
TUITION PAYMENT



Payment includes  

 ___ Tuition   ___ Air Mail Postage  	___ Payment by check   ___ Money Order  



___ Visa     ___ MasterCard     ___ Discover		#__________________________	



Cardholder's Name ______________________________	Expiration Date	 ____________



Taken for no credit ___________________________ Will take exams _________________



If the Board of Eduction is to be billed for registration fee, the following

authorization form must be filled in by the school official with

authority to approve such charges:



Registration fee for  _______________________________________________________
              							(Name of Student)



in _____________________________________________________________________
                                     (Course/s)



is to be charged to School District No. ____________ and bill sent to:



______________________________ at _______________________________________ 	
(Name of School Official)                              (School Address)



Signature __________________________________Title __________________________	



* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *  



OFFICE USE ONLY



Date Paid	________________



Amount Received	_________________



Processed By ____________________________________