Indiana University Bloomington
School of Public Health-Bloomington

Distributed Education Registration

Please use this form to register for Distance Education classes in the School of Public Health-Bloomington. If you encounter a problem while submitting this form, contact us by e-mail: roloughl@indiana.edu.


In the following form, some fields are marked as required. If you do not complete these fields correctly, you will be informed when you submit the form. If you receive an error message, use the browser's back button to return to the form with the data that you have entered.


Demographic Data

In this section, either a 10-digit Indiana University ID number or a U.S. Social Security number is desired. If you do not have either one, type the word "none" (without quotation marks) in the "IU ID or Soc Sec Number" field below.

Identification

First Name

*
Middle Name
Last Name *
IU ID or Soc Sec Number
Birth Date *
Gender *
Ethnicity
Citizenship *
Marital Status *

US Address

Street
City
State
Zip
Telephone Include area code

Foreign Address

Street 1
Street 2
City/Territory
Country
Postal Code
Telephone

E-Mail Address *


Enrollment Information

Intended Matriculation Semester/Year: Provide the semester and year in which you intend to enroll (i.e., matriculate).

Semester *
Year *

Specify your reason for seeking admission.

Personal Development
Renewing a Teaching License or Adding an Endorsement

Which license?

Some other reason
Please explain

Course Selection

Select one to three courses from the pull-down lists below.
Courses numbered 100-499 are undergraduate level.
Courses numbered 500 and above are post-graduate level.

HPER-R 599 Master's Thesis, HPER-R 641 Readings, and HPER-R 642 Internship, are offered each term for recreational therapy master's students. Please see your academic advisor to obtain authorization to take these courses.

Some browsers may require you to scroll to see all items in the drop down list

All selections are three credit hour courses.
Course Code (Section): Course Title (semester or session offered, delivery method, cost)


Educational History

Academic Transcripts: In the table below document your educational history by indicating the name of each institution (college and university) attended; degree received (if any); major field or fields of study; dates attended (from month/year and to month/year); and GPA earned. If you are currently enrolled in an academic program, indicate the month and yearyou expect to complete your studies; the degree you expect to earn (if any); and estimate your final GPA. Begin documenting your educational history with the most recently attended or current academic institution.

Academic Transcripts

Institution NameDegreeMajorFromToGPA


Residency Data

Prior Studies at Indiana University (IU)

Have you attended any campus of IU before?Yes No *

If yes, indicate semester/year first enrolled

If yes, also indicate semester/year last enrolled


Residency

State of Residence *
How long in the immediate past have you lived in that state? *
Military Home of Record (if applicable)
If you claimed "Indiana" as your state of residence, use the space to state why.

Complete the next two tables only if you claimed Indiana Residency. If claiming Indiana residency, please complete ALL blocks below. Failure to complete "Addresses" and "Employment" may result in a non-resident classification.

Addresses: In the table below, list the dates and addresses of the places where you have lived for the past five years.

FromToStreetCityState

Employment: If you have been employed during the last twelve months, provide the information requested below.

FromToEmployer's Name and AddressNature of the work (e.g., full or part time)


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