George Mason University Contract Course

VISUAL IMPAIRMENT CONSORTIUM COURSEWORK George Mason University Contract Course Kellar Institute, M.S. 1F2, Fairfax, VA 22030-4444 Enrollment Form

Course: EDSE 418/518 Section: 6V1 Credits: 3 Title: Curriculum & Assessment for Students with Visual Impairments Semester: Spring - 2009 Instructor: Course Dates: 1/22/09 – 4/30/09 (4:00p.m. – 6:40p.m.) Tuition: $148.00 per credit hour - Payment must be received within 48 hours of the first class meeting! (If using a credit/debit card, pay your tuition online at http://gse.gmu.edu/programs/sped/cohort ).

SSN: - - G# ______Date of Birth ______

______(Please Print) Last Name First Name MI Maiden or Other

Permanent Address:

Street

______City State Zip Code E-mail Address

Home Phone Work Phone

The following questions are for our information only. Your answers will not affect your enrollment status. Your cooperation is voluntary. As an equal opportunity/affirmative action institution, the university must ask you to identify yourself in regard to these race/ethnic groups. Sex / / Male Date of Birth Ethnic Group/Race / / American-Indian(I) / /Hispanic(H) / / Female / / Black(non-Hispanic)(B) / / Caucasian(W) Mo/Day/Year / / Asian or Pacific Islander / /Other _____ EDUCATIONAL SCHOOL (including current GMU admission) Degree Pursued Yr. Degree HISTORY Completed OR Expected Undergraduate

Graduate

HONOR CODE With the approval of your enrollment request, are you willing to accept the obligations imposed by the Honor System as it operates at George Mason University? Yes No (Any individual answering “no” will not be enrolled in GMU courses)

Signature Date ______