Phone: 570-484-2006 Office Hours: Monday - Friday, 8:00 AM - 4:00 PM Fax: 570-484-2734
WALK-IN REGISTRATION FORM All information must be completed
***Note: Non-degree students are not eligible for state and federal financial Aid.***
Courses to be enrolled Undergraduate Graduate
Have you ever applied for formal admission to Lock Haven University? Yes No
Previous College/University Attendance
College/university name and address Degree and date earned, if applicable
Semester and year for which you are registering Fall Spring Summer 1 Summer 2 Summer Extended Year
Social Security Number [will be used as student identifier until LHU student ID number is assigned] Warning: You are submitting information over an unsecure site; if you choose not to provide your social security number, you will be contacted for the number by telephone.
Name (last) (first) (middle initial)
Maiden Name (if applicable)
Street Address
City State Zip
Telephone Number (including area code)
Cell/Mobile Phone Number (including area code)
Date of Birth January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
Business Telephone Number (if applicable)
Residency Status County State Country
Local Address (if different from above)
Street or PO Box
Phone (including area code)
Ethnic (for reporting purposes only) African American or Black, not Hispanic American Indian or Alaskan Native Asian or Pacific Islander Hispanic, Chicano, Mexican American, Latino White, not of Hispanic Origin International Student
Sex Female Male Email Address
Marital Status (If you choose not to provide this information, please select "not indicated.) Single Married Divorced Widowed Not indicated
High School Information
Name and address of high school
Date of high school graduation
Course Choices
1st Choice (course # & sec) Alternate Choice (course # & sec)
2nd Choice (course # & sec) Alternate Choice (course # & sec)
3rd Choice (course # & sec) Alternate Choice (course # & sec)
4th Choice (course # & sec) Alternate Choice (course # & sec)
5th Choice (course # & sec) Alternate Choice (course # & sec)
09/17/2007
