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Special Student Application

Please submit this form and applicable fees at least 14 days prior to the term of enrollment

Student information

First Name:
Last Name:
Street or PO Box:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
(the college will contact you via this email address.)
Sex: M F
Social Security number: - -
Date of birth:
Citizenship: US

alien registration number:
Marital status:

Religious Affiliation:


Enrollment objectives


Date of expected enrollment:
Enrollment status:
Please check one:

Do you plan to obtain your degree from Augustana?
I plan to enroll in the following programs at Augustana:


Academic background


College or High school where you were most recently enrolled:
Have you previously attended Augustana College?
Dates of attendance:
(if you have never been enrolled at Augustana previously please have your high school or college transcripts forwarded to the College.)
Please list all other educational experiences (Please begin with your high school information, then list other colleges)
Institution Name Location Dates attended Reason for leaving or degree earned


Family information

Contact information of parent or guardian for official College communication: (does not apply to independent students)

Street or PO Box:
Home Phone:
Work Phone:
Cell Phone:
Preferred Contact:
Relationship to Student:


Auditors only

(Auditors must also complete and adhere to the policies in the Authorization to Audit Form available on-line and in the Office of the Registrar)


I plan to audit the following course(s):
Department Course number and section Course Title Instructor

Please submit all applicable fees to Augustana College Office of Admissions, 639 38th St., Rock Island, Ill., 61201, or fax 309-794-8797. Questions? Call 309-794-7341 or email

By re-entering your name below you are authorizing the use of this document as your official application.
Applicant’s Signature: