PROFESSIONAL EXCELLENCE BADGES

Please complete this form to register for your micro-credentialing coursework.

Today's Date Today's Date / MM / DD YYYY
Term you're registering for (select ONE):

Term you're registering for (select ONE): Summer Fall Spring
Year
PERSONAL INFORMATION
Last Name
First Name
Previous Name (if you attended under a different name at some time)
Middle Name (or Initial)
Preferred Name (Nickname, if chosen)
Gender Choice (select ONE)

Gender Choice (select ONE) Male Female Undisclosed
Social Security Number (if you've never taken or taught a class at the University before and are not in UR Student)--numbers only--ENCRYPTED
Date of Birth Date of Birth / MM / DD YYYY
Citizenship Status (select ONE)

Citizenship Status (select ONE) US Citizen Permanent Resident (with Green Card) International Student
If international, what type of visa do you have?
Country of Citizenship (Select one)
If you have dual citizenship, in which country is your other citizenship?
Highest degree you have completed:

Highest degree you have completed: Bachelor's Master's Doctoral
CONTACT INFORMATION
Mailing Address (NOT work address, please; include PO Box, if used) Mailing Address (NOT work address, please; include PO Box, if used)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
New York County (REQUIRED for NY Residents)
Preferred Phone Number (where you can be reached during class) Preferred Phone Number (where you can be reached during class) - ### - ### ####
Phone Type:

Phone Type: Cell phone Land line phone
Work Phone Number Work Phone Number - ### - ### ####
Phone Type:

Phone Type: Cell phone Land line phone Office
Preferred Email
EMERGENCY CONTACT INFORMATION
Name of person we should contact if you are taken ill during class:
Your Emergency Contact's relationship to you:
Emergency Contact's phone number Emergency Contact's phone number - ### - ### ####
Emergency Contact's Phone Type:

Emergency Contact's Phone Type: Cell phone Land line phone
Emergency Contact's e-mail:
Are you a UR Tuition Benefit Eligible Employee?

Are you a UR Tuition Benefit Eligible Employee? Yes No
UR Employee Benefit Eligibility

Visit: https://www.rochester.edu/human-resources/benefits/programs-perks/tuition-benefits/
to review your benefit eligibility and employee salary band waiver percentages.

Regular Full-Time and Part-Time Faculty/Staff Earning: < $64,900
(Employee Tuition Salary Band 1):
➢ 95% Tuition Waiver
Regular Full-Time and Part-Time Faculty/Staff Earning: $64,900-$138,500
(Employee Tuition Salary Band 2):
➢ 90% Tuition Waiver
Regular Full-Time and Part-Time Faculty/Staff Earning: > $138,500
(Employee Tuition Salary Band 3):
➢ 80% Tuition Waiver
Gap in coverage if UR employee benefit is applicable:

Gap in coverage if UR employee benefit is applicable: 5% 10% 20% I am a UR Employee not utilizing employee benefits I am NOT a UR Employee and will be self paying (not eligible for student loans)
Anticipated Enrollment

Anticipated Enrollment 1 credit (one class) 3 credits (one class) 4 credits (two classes) 6 credits (two classes)
PAYMENT AGREEMENT:

By typing my full legal name in the field below, I acknowledge my understanding that:
*I may forfeit my tuition award or benefit, if I fail to satisfactorily complete a class;
*Should I fail to pay any outstanding balance promptly, the University has the right to assess late fees and/or collection costs and to place holds on my account preventing future registrations or printing transcripts.
Badge Track

Badge Track Diversity, Equity, and Inclusion Leading Organizational Innovations Professional Learning Policy and Social Change Decision Making with Data Online Learning Leading Healthcare Education
COURSE REGISTRATION
See UR Student for details or contact admissions@warner.rochester.edu for recommendations/assistance.
Class #1 Section Number
Must be between 1 and 2 digits. Currently Entered: 0 digits.
Course Number Prefix

Course Number Prefix ED EDE EDF EDU
Course Number (404, 506, 545L, etc.)
Number of credit hours

Up to 9 credits of coursework can be taken as a non-matriculated student before matriculation into a Warner program is required.
Are you auditing (observing only) or taking this class for credit?

Are you auditing (observing only) or taking this class for credit? Audit Credit
Course Title
Course Instructor
Class #2 Section Number
Must be between 1 and 2 digits. Currently Entered: 0 digits.
Class #2 Course Number Prefix

Class #2 Course Number Prefix ED EDE EDF EDU
Class #2 Course Number (404, 506, 545L, etc.)
Class #2 Number of credit hours

Up to 9 credits of coursework can be taken as a non-matriculated student before matriculation into a Warner program is required.
Class #2: Are you auditing (observing only) or taking this class for credit?

Class #2: Are you auditing (observing only) or taking this class for credit? Audit Credit
Class #2 Course Title
Class #2 Course Instructor

PROFESSIONAL EXCELLENCE BADGES

PROFESSIONAL EXCELLENCE BADGES

PERSONAL INFORMATION

CONTACT INFORMATION

EMERGENCY CONTACT INFORMATION

UR Employee Benefit Eligibility

COURSE REGISTRATION See UR Student for details or contact admissions@warner.rochester.edu for recommendations/assistance.

COURSE REGISTRATION
See UR Student for details or contact admissions@warner.rochester.edu for recommendations/assistance.