CPE Course Listing

STUDENT ENROLLMENT FORM
For assistance with the enrollment form, please call: 816-235-1188 or email: umkc-continuinge@umkc.edu

*Please note: All starred items are required fields.*
Course Selection
Please check the box beside the course(s) you would like to enroll in.*
[table id=CPECourses /] I have selected a minimum of one course from the Course Listing above.
Please type the last name of your course’s instructor here:

Please fill in text box with appropriate information.
Demographics
First Name*: Last Name*:
Middle Name: Prior/Maiden Name:
UMKC ID#: Date of Birth (MM/DD/YY)*:

Contact Information
Number Street and Apt #*: City*:
State (2-digit abbreviation)*: Zip*:
County*:
Cell/Personal Phone*: Work Phone:
Personal Email*:
Work Email:
School/Organization: Number of Years in Education:

Optional Demographic Information
Gender: Female Male
Veteran: Yes No

To help UMKC better serve its student population and design programming that is more inclusive, and in an effort to remain compliant with federal, state, local, and grant-related organizations, please indicate your ethnic or racial background below:

Are you Hispanic/Latino? Yes No

Please check the box next to all races that apply.
American Indian/Native Alaskan
White/Non-Hispanic
Asian (Chinese, Filipino, Japanese, Korean, Asian Indian or Thai)
Asian (underrepresented)
Native Hawaiian/Pacific Islander
Black/African American
Hispanic/Latino

UMKC Record – Prior UMKC Credit* Yes No     Year:
Enrolled in other UMKC courses this term?* Yes No
Prior Student at another University of Missouri Campus?* Yes No    
Where?: Year:

Residency Information
Are you a Missouri resident?* Yes No
Are you a resident of one of the following Kansas counties: Atchison, Douglas, Franklin, Jackson, Jefferson, Johnson, Leavenworth, Miami, Osage, Shawnee, or Wyandotte counties?* Yes No
How long have you been a resident of Missouri or Kansas counties listed above? (Number of Years)
Previous legal address, if less than one year at current legal address:

US Citizen
Permanent Resident     Alien Country of Citizenship
          Visa Type: Card Number:
Date of Issue:
Deferred Action for Childhood Arrivals (copy of I-797 with I-821/I821D noted)
Refugee or asylum (documentation required)

Please submit a copy of your resident alien card via physical mail.
**Please note: Students with F-1 and J-1 visa status are not eligible for part-time or Missouri Taxpayer Scholarships.**
**International visa students apply using a form offered by the International Student Affairs office at umkc.edu/isao**

Submit your Student Financial Responsibility Form here:
In order to process your enrollment form in a timely manner, please sign the Student Financial Responsibility Form (SFR) Signature Page that you will be directed to when you hit the Submit button below.