ENROLLMENT FORM - IUPUI Family, School, and Neighborhood

ENROLLMENT FORM
518 Indiana Avenue | Indianapolis IN 46202 | 317-278-9170
Engage.iupui.edu/professionaldevelopment | PDCE@IUPUI.edu
□ New Student □ Returning Student □ My information has changed since my last registration
First Name
Last Name
Date of Birth
Street Address
City
State
Daytime Phone
Evening Phone
E-mail Address
Zip
□ Yes, I am an IUPUI Employee (Call 317-278-2000 for more information.)
Organization/Employer
DEMOGRAPHIC INFORMATION:
THIS INFORMATION WILL BE USED IN A NONDISCRIMINATORY MANNER FOR REPORTING PURPOSES ONLY. YOUR COOPERATION IS APPRECIATED.
Gender:
□ Male □ Female
Ethnicity:
Household Income:
Formal Education Completed:
□ White/Caucasian
□ <$25,000
□ High school diploma or equivalent
□ Black/African American
□ $25,001-$50,000
□ Certificate
□ Hispanic/Latino
□ $50,001-$75,000
□ Associates Degree
Are you employed:
□ Native American/American Indian □ $75,001-$100,000
□ Bachelor’s Degree
□ Yes, part-time
□ Asian/Pacific Islander
□ >$100,000
□ Master’s Degree or higher
□ Yes, full-time
□ International (Please specify):
□ Prefer not to answer
□ No
_____________________________
□ Unknown
Primary reason for taking Continuing Education Courses?
Intended goal for taking IUPUI Continuing Education Courses:
□ Personal/professional fulfillment
□ Advance in my career in my current position through promotion
□ Increase specific professional skills
□ Learn or Advance skills that lead to a new job
□ Learn new professional skills
□ Retrain in a new field
□ Seeking Certificate/Certification
□ Learn new skills to start a business
□ Required CEU
□ Learn skills that lead to personal fulfillment
□ Elective CEU
□ Other: _____________________________________________________
□ Other:
__________________________________________________
How did you learn about IUPUI Continuing Education?
Which of these sectors best describe the industry in which you are
employed?
□ Ad in the Indianapolis Star newspaper
□ Ad in the IBJ newspaper
□ Technology
□ Arts, Culture, Tourism and
□ Ad in an online newspaper
□ Advanced Manufacturing Entertainment
□ Life and Health Sciences
□ Returning Student
□ Logistics
□ Agriculture
□ Word of mouth from former student
□ Education
□ Government
□ Word of mouth from a continuing education instructor
□ Non-profit
□ Professional association or organization website or newsletter
Tell us about your professional background:
□ the IUPUI website
□ Ad on a community calendar or community newsletter
□ Other: _____________________________________________
Do you have an IU connection? □ IU Employee □ IU Retiree □ IU Alumni □ Current IU Student □ None
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ENROLLMENT FORM
518 Indiana Avenue | Indianapolis IN 46202 | 317-278-9170
Engage.iupui.edu/professionaldevelopment | PDCE@IUPUI.edu
COURSE NUMBER
COURSE TITLE
COURSE FEE
TOTAL FEES $
THREE CONVENIENT WAYS TO ENROLL:
ONLINE: Credit card only. Visit
BY MAIL: Check or money order only
Engage.iupui.edu/professionaldevelopment.
Select Continuing Education & Professional
Development. Select “How to Enroll” and
follow the directions.
payable to IUPUI. Send enrollment form and
payment to:
Attn: Laura Barahona
Office of Community Engagement
518 Indiana Avenue
Indianapolis IN 46202
WALK-IN: Check or money order only
payable to IUPUI. NO CASH ACCEPTED. Bring
completed enrollment form and payment to:
Office of Community Engagement
518 Indiana Avenue
Indianapolis IN 46202
Hours: Mon-Fri, 8:30 am – 5:00 pm
REFUND POLICY: All cancellations will be subject to a $25 cancellation fee. Course fees will be refunded based on cancellation date as listed below:
• 6 days or fewer before class: 0% refund
• 7-14 days before class: 50% refund, less $25 cancellation fee
• 15 days or more before class: 100% refund, less 25 cancellation fee
If Professional Development and Corporate Education cancels a class, you will automatically receive a full refund. Refunds will be issued in the
same form as the payment was received. Please allow six weeks processing time for check refunds and 10 business days for credit card refunds.
BUDGET PAYMENT PLAN: Courses with fees greater than $500 may qualify for a Budget Payment Plan in which payments are divided into two equal
installments. Please call for more information.
COMPANY BILLINGS: Companies choosing to pay for employees to attend classes may be billed for classes. Please call for more information.
FOR MORE INFORMATION, CONTACT LAURA BARAHONA AT 317-274-5006 OR LMBARAHO@IUPUI.EDU.
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