CENTER FOR COMMUNITY ENGAGEMENT LEWIS & CLARK GRADUATE SCHOOL OF EDUCATION AND COUNSELING

Continuing Education Credit

The Following Information is Required

Legal Name: First

Last/Family

Chosen First Name

Chosen Last Name

Former Names

Address

Street Address

City

State/Province

Zip

Date of Birth

Social Security Number

L&C ID (if known)

If not a citizen of the U.S. are you a Permanent Resident?

Yes

Visa type:

The Following questions are optional

How do you describe your gender identity?

Pronouns

How would you describe your race? Are you Hispanic/Latino?

YesNo

Course Selection

This form is for continuing education courses only. These courses are not degree-applicable and offered only as pass/fail (CR/NC). Letter grades are not provided.

Term

Course Title & Start Date (YYYY-MM-DD)

Course #

Course Cost

You are responsible for all tuition and fees for any course,

workshop, event, or conference for which you register.

Total Due: $

Accessibility

If you have a disability that may impact your academic performance or participation in this course please contact the Center for Community Engagement (cce@lclark.edu or 503-768-6040) to discuss the accommodations that you need.

NOTE: If you are a Lewis & Clark graduate student and currently enrolled in an academic degree program please contact the Office of Student Accessibility in Albany Quadrangle (503-768-7192 or access@lclark.edu). Once you complete the intake process and the Accommodations Agreement, you may request to send your Accommodations Letter. OSA staff will then notify faculty of the accommodations for which you are eligible.

Center for Community Engagement - Lewis & Clark Graduate School of Education and Counseling 615 S Palatine Hill Rd, MSC 85, Portland, OR 97219-7899
Phone: 503-768-6040 | Email: cce@lclark.edu
go.lclark.edu/graduate/cce

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Asian	Native Hawaiian or other Pacific Islander	Other
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