EDG660 Course Registration Form

First Name:
Middle Initial:
Last Name:
Maiden Name:
Street Address:
Zip Code:
Phone (Home):
Phone (Work):
Phone (Cell):
Social Security #:
Ethnicity (Requested for federal reporting but optional)
Choose one or more of the following:
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Marital Status:
Religion (optional):
Country of Citizenship:
Visa Status:
Visa Type:
Bachelor's Degree Received: (You must provide a copy of your bachelor's degree to Nyack)
Date Received:
How did you hear about Nyack?
   YES, I understand that I am registering for EDG660 Current Topics/Teaching in the Age of Innovation and that I am responsible to pay $450 for this course before the course begins. This is a one credit Pass/Fail online class. I will receive a full refund only if I withdraw within the first week of the course. There will be no refund for the course after the first week. Registration and attendance at the Enhancing Teaching Effectiveness conference ($40 nonrefundable registration fee) is required to register for this course.
   YES, I certify that the above information is complete and true.
Nyack College is an educational institution that admits academically qualified students without regard to sex, age, race, color, religion, natural origin and ancestry, marital status, parenthood or handicap to all the rights, privileges, programs and opportunities generally available to students.