Extension Registration Form

Use this form to register for Extended Education classes.

NOTE: This form cannot be used to submit Open University, Graduate Continuous Enrollment, or Summer Session registrations.

Student Information

= Required field

Select your gender identity:*

Have you ever been enrolled at Cal Poly Humboldt?

Have you completed a Bachelor's Degree or higher?

Secure Information

Please supply the following information: Humboldt ID (or Social Security Number) and Date of Birth
This information is submitted via SECURE SERVER, and is requested pursuant to Section 41201, Title 5, Calif. Code of Regulation and Section 6109 of the Internal Revenue Code.

Humboldt ID or Social Security Number (000-00-0000):required

Your date of birth is required so that Cal Poly Humboldt may identify records that are unique to you.

required

Race/Ethnicity Information

Your voluntary response is requested to comply with Federal and State legislation. If the California State University system is asked to report only ONE summary race/ethnicity description for you, choose the ONE category below that you want us to report:

 
Courses

Enter the course information for the courses you want to take.

Course 1
$
Course 2
$
Course 3
$

$

$

Payment of Fees

If you owe a fee, please select how your fees will be paid. If you do not wish to make an online payment upon submitting this form, please select one of the other payment options.

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