Registration Form Hudson Valley Community College printable pdf download

College in the High School Program

Failure to pay by the stated deadline will result in NOT receiving college credit for the course(s) listed

below. Please consult the Questions & Answers Brochure for appropriate payment deadlines.

Hudson Valley Community College, 80 Vandenburgh Avenue, Troy, NY 12180-6096 (518) 629-4574

Student Record Information (SRI Form)

Social Security Number* __________________________________

Name* ____________________________________________________________________________________

Last

First

HVCC is required by federal law/regulations to collect your social security number (SSN) or correct individual taxpayer identification number

(ITIN) to file information returns with the IRS and to furnish a statement to you. In addition, your name on file with the College must match your

name as filed with the Social Security Administration. PENALTY: if you fail to furnish your correct SSN or ITIN to the College, you may be

subject to a penalty levied by the IRS.

Mailing Address _______________________________________________

____________________________________________________________

(

Check here for change of address)

City ____________________________________ State _____________ Zip Code __________________

Home Telephone ___________________________ Cell Phone _________________________________

Sex Code**

Date of Birth _____________________

Are you the family member of someone who served in the active United States military Armed Forces?

[ ] Yes [ ] No

As required by SUNY System, all students must answer the following two questions:

Have you ever been convicted of a felony? . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .

[ ] Yes

[ ] No

Have you ever been dismissed from a college or university for disciplinary reasons?

[ ] Yes

[ ] No

Are you Hispanic/Latino?**

[ ] No

[ ] Yes

If yes, what is your background? (select one)

[ ] Central American

[ ] Dominican [ ] Mexican

[ ] Puerto Rican

[ ] South American

[ ] Other/Hispanic/Latino

All students, please indicate your race (select one or more)**

[ ] American Indian or Alaskan Native [ ] Asian

[ ] Black or African American

[ ] Native Hawaiian or Other Pacific Islander

[ ] White

[ ] Two or More Races

[ ] Unknown

**NOTE: Hudson Valley Community College is required to furnish New York State with gender and ethnic data for every student.

What is your Home High School? ________________________________________________________

Expected Date of High School Graduation _________________________________________________

Semester/Year: Spring 2017 – January 17 to May 12, 2017

Please list/write the Online Learning course(s) you would like to enroll below:

CRN

Subject Code

Course #

Section #

Course Title

Credits

I hereby give permission to Hudson Valley Community College to send my grades and transcripts to my high school guidance office. 10/25/16

___________________________________________________

__________________________________________________________

Student Signature

Date

Guidance Counselor/High School Contact

Date

Please return to the Registrar's Office, HVCC, 80 Vandenburgh Avenue, Troy, NY 12180-6096 or via fax at (518) 629-8094

Registration Form Hudson Valley Community College

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