UpN Coding Registration Form

If you see this don't fill out this input box.

First Name*

Middle Initial

Last Name*

Other Name(s) Used

SSN*Enter Social Security Number

Address1*Address1

City*City

State*State

Zip*Zip

Phone*

E-mail Address*

Date of Birth*

GenderEnter your gender

EthnicityEnter your ethnicity

High School Name*Enter High School Name

High School Graduation Year*High School Graduation Year

Have you ever been dismissed from a college for disciplinary reasons?

Yes

No

Citizenship* Please Select U.S. Permanent U.S. Resident Non-resident alien OtherSelect country of residence

Course Option

UpNCoding

Child Development Associate (CDA)-Malone Campus

Child Development Associate (CDA)- Saranac Lake Campus

Please select course:

Payment Method

I would like to pay online

I would like to pay via check

I would like to make payment arrangements

If online payment or check-by-mail is chosen, you will receive an e-mail with instructions on how to proceed after submitting request.

Verification

I am the individual requesting to be registered for the courses listed above.

I understand, that by signing this registration form, I am formally registered for the above indicated semester and have incurred a financial obligation to pay for these courses unless I formally drop the courses in writing prior to the start of the semester.

Signature*Enter your full name - Parent/guardian signature if registrant is under 18 years of age.

Date*Enter today's Date

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