Special Student Application

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Special Student Application

Please submit this form and your most recent transcript at least 14 days prior to the term of enrollment.

Student Status*

CSD Post-Baccalaureate Part-time/non-degree Former student applying to return to Augustana Auditor Non-Augustana student applying to take Augustana courses through Acadeum Augustana Next Cooperating teacher

Augustana Next community college partner

Eastern Iowa Community Colleges Black Hawk College

Student information

Name*

First Name

Middle Name (optional)

Last Name

Preferred name

Date of birth*

Former name (if applicable)

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Cell phone*

Home phone

Work phone

Email (enter your Augustana email if applicable)*

In what degree program are you enrolled at your current school?

Associate of Arts Associate of Science

Sex

Male Female

Other:

Date of birth*

Are you a U.S. citizen?*

Yes No

I am a citizen of:*

Alien registration number

Marital status

Single Married

Spouse's name

First Name

Last Name

Ethnicity

Religious affiliation

Emergency contact information

Name of emergency contact*

First Name

Last Name

Preferred phone*

Other phone

Relationship to student*

Academic background

High school graduation year*

College or high school where you were most recently enrolled*

Have you previously attended Augustana College?*

Yes No

Do you have a degree(s)?*

Yes No

Please list your degree(s)

Dates of attendance

Please have your high school or college transcripts forwarded to the College.

Please list all other educational experiences, beginning with your high school, then other colleges. (Institution name, location, dates attended, reason for leaving or degree earned)

Family information

Contact information of parent or guardian for official College communication (does not apply to independent students)

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Cell phone

Home phone

Work phone

Preferred contact

Cell phone Home phone Work phone

Relationship to student

Auditors only

Auditors must also complete and adhere to the policies in the Authorization to Audit Form available online and in the Office of the Registrar.

I plan to audit the following course(s) (Department, course number and section, course title, instructor)*

Auditors must also complete and adhere to the policies in the Authorization to Audit Form available online and in the Office of the Registrar.

I plan to audit the following course(s) (Department, course number and section, course title, instructor)

Please submit all applicable transcripts to:

Augustana College Office of Admissions
639 38th St.
Rock Island Ill., 61201

Or fax 309-794-8797. Questions? Call 309-794-7341 or email admissions@augustana.edu.

By signing your name below you are authorizing the use of this document as your official application*

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Special Student Application

Student information

Emergency contact information

Enrollment objectives

Academic background

Family information

Auditors only