Blinn College

Student Information Form for December Minimester 2009/2010 and Spring 2010

What do I do if the automatic email does not arrive?

* Required information

First/Last Name *
Blinn ID Number *
E-mail Address *
Phone Number*
Semester* Please fill out a separate form for each semester.	December Minimester 2009/2010 Spring 2010

Please check one of the options below (please check only one)

Current Student: I am enrolled in a distance education course and I am submitting my contact information.

Prospective Student: I am not a student but I want more information on the distance education program and the courses offered through distance education. Please skip the next section and go directly to the description and ask your questions.

This form does not enroll you at Blinn College and it does not register you for these courses.

Please select the Internet Course(s) that you are enrolled in this semester. If you are enrolled in a blended course, please use the last item only.
	Select your Course	Section the Section
1)
2)
3)
4)

BLENDED COURSE:
	You do not have to fill out this form if you are taking a blended course. If you want to fill it out, please list your Blended course in the blank above.

---- This section is for statistical purposes only----
Are you a:
How many Distance Education Courses have you taken?
How did you hear about Distance Education Courses?
If other, please list:

Please use the space provided below to ask any questions that you have about the Distance Education Program:

Please select one of the following:

Please click SUBMIT once. It may take a moment so please be patient.

Page Last Updated: October 21, 2009