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School of Education

Pacific Union Conference Registration


This form is to be completed by Pacific Union Conference teachers planning to take courses at La Sierra University.The completed form is to be submitted to your superintendent of schools, who will forward it to La Sierra University's Records Office. Once this form has been received and processed, course registration instructions will be sent to you by email from the La Sierra University Records Office.

An authorization form must be submitted for each term (quarter) of attendance.

First Name:  
Middle Name:  
Last Name:  
Maiden Name:  
E-mail Address:  
Phone Number:  
Date of Birth:  
Mailing Address:  
Zip/Postal Code:  

Other (Type of Visa):  
Marital Status:  
Religious Affiliation:  
Phone Number:  
Enrollment for the year:  

Indicate the number of hours you plan to take each quarter:   Summer Hours
  Fall Hours
  Winter Hours
  Spring Hours
Highest degree earned:  
Degree earned from:  
Degree earned date:  

The above named teacher who is currently teaching and meets the provisions of the Pacific Union Conference Education Code Section E10-152is authorized to attend:

La Sierra University (Check all that apply) Remove certification deficiency including required undergraduate courses
Upgrade from Basic to Standard Certificate
Renew Standard Certificate
Upgrade from Standard to Professional Certificate
Renew Professional Certificate
Meet endorsement requirement in
Meet CDC licensing requirements
Meet CDC credential requirements
Meet an approved M.A. degree or 5th year program

Conference of employment:

By initialing here, I authorize the release of my transcript to Pacific Union Conference, and affirm that all of the information contained on this form is true, complete, and correct to the best of my knowledge.

School Where Employed:  

FINANCIAL INFORMATION: A scholarship to cover tuition and registration fees is given to teachers who are authorized to attend on-campus courses at La Sierra University.This tuition waiver policy applies to all courses offered which will meet credential renewal requirements. Each applicant is eligible for 12 quarter hours per academic year of coursework up through the requirements for the M.A. degree and/or professional certification in teaching, administration, counseling psychology, special education and child development. For additional information, see Education Code Section E10-152 for the policy governing attendance. If a grade of "D" or "F" is received in a course, or if you take a course outside of an approved program, you may be charged tuition.

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