Adult Continuing Education

First: Required

Middle: Required

Last: Required

Gender: Required

Date of Birth: Required

Citizenship: Required

Street: Required

City: Required

State: Required

Zip Code: Required

E-mail: Required

Home Phone: Required

Cell Phone: Required

Employer: Required

Employer Address & Phone: Required

Plan to Attend: Required

Year: Required

Course(s) Interested: Required

1. Are you Hispanic/Latino?

2. Regardless of your answer to the prior question, please select one or more of the following ethnicities that best describe you:

1 American Indian or Alaska Native (including all Original Peoples of the Americas)

2 Asian (including Indian subcontinent and Philippines)

3 Black or African American (including Africa and Caribbean)

4 Native Hawaiian or Other Pacific Islander (Original Peoples)

5 White (including Middle Eastern)

High School Name and Address: Required

Graduation Date: Required

College or University Name & Address:

Dates Attended:

Degree:

Do you plan on taking course for: Required

Do you intend to apply for admission to Dickinson College in the future?

Have you taken classes at Dickinson College in the past?

Billing Address:

Student Signature: Required

Signature: Required

Application