FWHEC Enrollment Request Form

Today's Date: 

Student ID Number: SSN:

Student's Name     Last:      First:      Middle:

Street Address:        City:
State: Zip:        Country:

Email Address Date of Birth:

Suffix: Maiden name or other former name:  

Ethnicity: White Non-Hispanic Asian or Pacific Islander Black Non-Hispanic Hispanic American American Indian/Alaskan Native Non-Resident Alien Other

Student's Host institution? Huntington University Indiana Inst of Technology IPFW Ivy Tech State College Manchester College Taylor University-Fort Wayne University of Saint Francis

Student's Home institution? Huntington University Indiana Inst of Technology IPFW Ivy Tech State College Manchester College Taylor University-Fort Wayne University of Saint Francis

Enrolling what semester?

Enrolling for what course at Host institution? Subject/Title:  

• Course# Cr. Hours:

Replacing what course at Home institution? Subject/Title:  

Course# Cr. Hours:

Have you ever attended this host institution? Yes No If yes, when?

Advisor Signature: Date:

Advisor Campus Extension: