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School Divisions Professional Learning Registration Form


  • No spaces can be reserved without registration and payment.
  • Space is available on a first come, first served basis.
  • Within two business days you will receive an email confirmation with receipt of your registration request and instructions on how to pay your tuition.

 

PERSONAL INFORMATION
Title: (Dr., Mr., Mrs., etc.)
First Name:
Middle Initial:
Last Name:
Are you a U.S. citizen?:
If no, are you a Permanent Resident?:
If not a U.S. Citizen, what is your country of birth?
If not a U.S. Citizen, what is your country of citizenship?
If not a U.S. Citizen, what Visa status do you hold?
Visa #
Home Address:
Home Phone:
Highest Level of Education Completed:
School/Place of Employment:
School Division:
Work Address:
Occupation/Title:
Work Phone:
Email:

Please fill out the following information. It is required as a matter of legal reporting requirements applicable to Regent University. It will not be taken into account in any admission or academic decision, nor in the administration of any program at the University.

Gender:
Date of Birth:
Ethnic Origin:
How did you hear about Regent?
REGISTRATION INFORMATION

Submitting this form indicates that I am agreeing to be registered for the following listed courses and that I take full financial responsibility unless a written request to withdraw is received seven days after the start date of the courses and the written request is granted by the Dean.

 

Note: Regent University reserves the right to change or cancel courses, so please call or visit our website (www.regent.edu/education) to confirm the location, date and time of your course prior to the first day of class.

Course Number & Title:
If you are registering for an online course, please indicate if you have taken the EDUC 500 Blackboard Online Orientation.
Location: