OFFICE OF THE REGISTRAR
KUTZTOWN UNIVERSITY OF PA
Kutztown, PA 19530
Undergraduate Registration
Non-Matriculated Students Only
Semester and Year of Entry: ___________________________
Student ID (Previous Student Only) _____________________ SSN (New Student Only) _______________________
Name: _____________________________________________________________________________________
Last
First
Middle
Legal Address: _______________________________________________________________________________
Street
City
State
Zip
County: ______________________ Maiden Name: ____________________________
Male
Female
Email: ______________________________________________ Date of Birth: ___________________________
Home Phone: ______________________ Cell: ______________________ Business: _________________________
Emergency Contact: ________________________ Relationship: _________________ Phone: _______________
Kutztown University is committed to assuring equal opportunity to all persons regardless of race, color, religion,
national origin, ancestry or gender. This policy extends to employment within and admission to the University and is in
compliance with all federal laws, including Title IX of the Educational Amendments of 1972.
1.What is your Ethnicity?
Hispanic
Non Hispanic
2.What is your Race? Mark one or more races to indicate what you consider yourself.
White
Asian
American Indian/Alaskan Native
Black/African American
Native Hawaiian/Pacific Islander
Have you graduated from or attended KU as a matriculated (accepted) candidate before?
Yes
No
Last attended KU: Semester ___________ Year ____________ Country of Citizenship: ______________________
Advant*Age Student:
Yes
No
Visa Type:
Permanent
Student
Other
If you have attended other college(s) or Kutztown University previously, complete the following. Any omissions will
cause consideration of a fraudulent applicant.
College: ___________________________________________ Dates of Attendance: _______________________
Degree Earned or Number of Credits: _____________________________________________________________
REGISTRATION:
Course: ______________________________________________________________________________________
Prefix
Course #
Section
Title
Credits
Course: ______________________________________________________________________________________
Prefix
Course #
Section
Title
Credits
Course: ______________________________________________________________________________________
Prefix
Bill Me
Course #
Section
Title
Pennsylvania Resident
Credits
Non-Resident
PLEASE SEE REVERSE SIDE FOR REQUIRED SIGNATURE.
Information Release: Directory Information is released unless the student indicates he/she does not wish the information be
released. This is accomplished by notifying the Registrar’s Office in writing or can be done through myKU.
I testify that the information given is both truthful and correct. I authorize you to use my social
security number for student identification and records.
Signature: ____________________________________________________ Date: ________________
MAIL OR FAX COMPLETED FORM TO:
Kutztown University, Registrar’s Office
PO Box 730, Kutztown, PA 19530
Fax: 610.683.1586
NOTICE
Kutztown University of Pennsylvania
A Member of the State System of Higher Education
Notice of Availability of Annual Safety & Security / Fire Safety Reports
Kutztown University is committed to assisting all members of the community in
providing for their own safety and security. The annual security report and
crime statistics and fire safety and fire statistics are available at:
http://clery.kutztown.edu
This report includes statistics for the previous three years concerning reported crimes that occurred oncampus, in certain off-campus buildings or property owned or controlled by Kutztown University, and on
public property within or immediately adjacent to and accessible from the campus. This report also
includes institutional policies concerning campus security, such as policies concerning sexual assault and
other matters. You can obtain a copy of this report by contacting the Department of Public Safety & Police
Services at one of the following: Mailing address: Kutztown University, Department of Public Safety &
Police Services, P.O. Box 730 Kutztown, PA 19530.
Phone: 610-683-4002 / Fax: 610-683-1530
Email: publicsafety@kutztown.edu
Rev. 9/11