Application And Registration Form printable pdf download

The Early College Online Academy : Application and Registration Form

To be completed by student, each semester: PLEASE PRINT CLEARLY

Name: _________________________________________________ High School/Home School: ___________________

(First)

(M.I.)

(Last)

County

Permanent Address: ______________________________________________________

: _____________

(No.)

(Str.) (City)

(State)

(Zip)

Mailing Address (if different)_______________________________________________ County: _____________

(No.)

(Str.) (City)

(State)

(Zip)

Home Phone No.: ( ____ ) _____ - ________

Alternate Phone No.: ( ____ ) _____ - ________

Social Security No.: _______-_______-_______

Date of Birth: _____ / _____ / _____

Gender: Male ______ Female ______

Email__________________________________________

Semester of Enrollment: Fall _____ Spring _____ Summer _____ Expected HS Graduation Date: _____________

Have you taken credits at SUNY Broome before: No ____ Yes ____Are you a Fast Forward Student? No ____ Yes ____

Future Intended Major (if known)_______________________________________________________________________

Courses

Note: Students wishing to take a course requiring a prerequisite must provide proof (unofficial transcript, grade report)

of successful completion of the prerequisite course, or receive instructor permission to enroll in the course.

Course Name/Number

Section

CRN

Credits

Tuition

Sample: PSY 110 – General Psych

Y06

34566

$183

All of the information given above is true and correct. I understand that Early College online courses incur tuition charges that must

be paid promptly. If I decide to change my education plans, I will notify SUNY Broome in writing. I realize that non-attendance in

class will not relieve me of financial responsibility. To the best of my knowledge, I have met all prerequisites for enrollment in the

courses above. I agree to abide by all College rules and regulations.

If students wish to transfer SUNY Broome credits back to the high school, they must obtain separate, written permission from their

high school principal. This is done independently, and Early College does not become involved in this process.

Student Signature/Date______________________________HS Advisor Signature/Date_____________________________________

Parent Signature (if student is under 18)________________________HS Advisor Name/Email*______________________________

HS Advisor Signature_______________________HS Counselor Signature (if differs from advisor)____________________________

A VALID CERTIFICATE OF RESDIENCY IS REQUIRED. Download the form at

Application And Registration Form

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