COURSE PRE-REGISTRATION FORM

 

To enroll in a face to face or online course or to request a specific educational service, please complete the following online, registration form shown below.  Please be sure to use your complete name (Last, First, and Middle Initial).  To secure or finalize your class seating and enrollment,  please feel free to visit the online "Tuition Payment Center" located just beneath this class registration form icon located on this website.     Thank you!

* Required fields
Name *
E-mail Address *
Alternate email address:
Name of Parent/Guardian (if applicable)
Mailing Address
City/Town
State
Zip Code
Home Telephone Number
Daytime/Work Telephone Number
Date of Birth
Identification No. (Last 4 digits of Social Security No. for I.D. purposes only)
School/Organization/Institution/Company You are Affiliated With Along with Contact Supervisor's Name, School/School District Address & Funding Code
Education Service Requested *
Indicate any disabilities you may have (if applicable)
Course(s) / Seminar(s)You Are Registering For (Including Course No., Title, and Cost)
Enrollment Program Type:
Number of C.E.U.'s or Instructional Credit Units Registering for (Contact office for details if needed):
Class Session/Semester You Are Registering For: *
Preferred Day and Time for Class (Please indicate two optional time slots)
REGISTERING FOR ED2GO ONLINE COURSE(S)
Total Tuition Cost for Registered Course(s) and/or Seminar(s):
Form of Payment for Tuition
Name of College, University, or K-12 School Currently or Previously Attended:


Please enter the code shown above and click the 'Submit Form' button. This additional step is required to help protect against message spam.



For non-electronic tuition payments, please mail your payment to:  Student Support Services, DeLorge International University Centre, School of Professional Studies, 126 E. Gordon Street, Suite   201, Kinston, NC 28501.  For credit card or debit payments, click       and visit our secure online tuition payment center.