Office of Records and Registration
640 Bay Road, Queensbury, NY 12804-1445
CALL: 518.743.2279 | FAX: 518.832.7601 | EMAIL: registrar@sunyacc.edu
Non-Matriculated Student Registration Form
NON-MATRICULATED STUDENT POLICY: Non-matriculated students are not eligible to receive financial aid (i.e. Pell, TAP, Loans,
etc.). Non-Matriculated Students receive grades and GPA calculations but do not receive an academic standing or academic honors.
Non-matriculated students can earn a maximum of 36 credit hours at SUNY Adirondack prior to matriculation. Students nearing the
36 credit hour limit should contact the Admissions Office to learn more about matriculation. Information about matriculation are available
in the College Catalog at; http://catalog.sunyacc.edu/admissions/quickguide.
I understand the non-matriculated student policy outlined above and available in the Catalog: ______________ (Initial)
NON-MATRICULATION STEPS:
Submit this completed form to the Office of the Registrar (via email, fax, or mail) including;
o A form of identification (i.e. Government Issued ID, Marriage License, Social Security Card, or Court Order).
o IRS regulations require the College to collect Social Security numbers for students registered in credit-baring coursework. A
staff member can schedule a phone call or Zoom session for you to provide this information for our records if you prefer instead
of submitting via this form.
o Transcript information as evidence of course prerequisite with this form (if applicable).
Submit proof of immunizations as required by relevant NYS Public Health Laws to the Office of the Registrar (students taking less
than six in-person credit hours are exempt from this requirement but are strongly encouraged to submit) by the first day of class.
Submit a Certificate of Residence to the Student Accounts Office within 60 days of the beginning of the semester.
GENERAL PERSON INFORMATION:
Semester: Summer Fall Winter Spring Year: 20___________
Student Type:
New (first time/transfer) student at SUNY Adirondack for the semester of registration
I have previously registered for or earned credit at SUNY Adirondack.
If you are a returning matriculated student at SUNY Adirondack, please contact advising@sunyacc.edu.
Student Name: _______________________________________________________________________________________________
Former Name: _______________________________________________________________________________________________
Social Security Number or Banner ID (former students): _______________________________________________________________
A staff member from the Registrar’s Office can schedule a phone call or Zoom session for you to provide this information for our records if
you prefer instead of submitting via this form. If you would like us to do this, please note this and make sure your contact information is
correct for us to schedule a time or call and speak to you.
Date of Birth (MM/DD/YY): _________________________________ Sex: Male Female
Permanent Address: ___________________________________________________________________________________________
Phone (Including Area Code): ___________________________________________________________________________________
Email Address: _______________________________________________________________________________________________
We will be sending follow up communications to this address. Please provide a personal email you check regularly.
CITIZEN, RACE, AND ETHNICITY INFORMATION:
Are you a US citizen? Yes No *If no, are you a permanent resident? Yes No
If you are a non-citizen, we will require a copy of your visa. Visa Type: ______________ Nation of Birth/Citizen: ____________________
Foreign Students must provide their permanent non-United States address: ________________________________________________
___________________________________________________________________________________________________________
Race (check one or more): American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Pacific Islander White
Are you Hispanic/Latino? No/Prefer not to answer
Central American Dominican Mexican Puerto Rican South American Other Hispanic/Latino
EMERGENCY CONTACT INFORMATION:
Emergency Contact Name: _____________________________________________________________________________________
Relationship to Student: ______________________________ Emergency Contact Phone Number: _____________________________
Updated 12/10/2020
EDUCATION INFORMATION (Complete all applicable information)
Name of High School: ____________________________________________ Year Graduated: _____________________________
GED/TASC Date Completed _______________________________________
Official Record of English Assessment Score (TOEFL, IELTS, etc.) for International Students: _________________________________
Colleges Previously Attended: ___________________________________________________________________________________
Colleges Currently Attending: ____________________________________________________________________________________
Have you ever been dismissed and/or suspended from a college for disciplinary (non-academic) reasons? Yes No
REQUESTED COURSES
CRN
Subject and Course Number
Section Number
Credits
STATEMENT OF FINANCIAL RESPONSIBILITY AND REGISTRATION VERIFICATION
By registering for classes at SUNY Adirondack, I acknowledge and agree that I am financially responsible for all charges related to my
registration and housing.
I understand that if financial payment and/or arrangements have not been made by the due date, the College reserves the right to remove
me as a student for non-payment, deny me access to my registered classes, and/or place a "hold" on my student records restricting me
from registering, graduating, and/or obtaining a transcript until the account is paid in full. I am responsible for all late charges incurred.
Failure to attend classes does not absolve me from financial liability. In all cases it is my responsibility to drop classes by the published
drop/add date(s) and I accept financial liability for these classes in accordance with the SUNY Adirondack Bill Adjustment/Liability
Schedule. SUNY Adirondack may call (personally or automated) or text any phone number that I have provided to the College and leave
a message regarding any outstanding account I have. I understand that, if the College texts me, I will be able to opt out. The College
may use a collection agency or take legal action for any account balance due and I will be responsible for all charges owed which may
include collection and/or litigation costs or attorney fees.
I understand that the College will (1) electronically post my 1098-T form (Tuition Statement) to my Banner account so I can download the
form for tax purposes and (2) mail a paper copy of my 1098-T to my primary address on file. I understand that I am responsible for
providing the College with updated contact information either through Banner or in person at the Registrar's Office in Warren Hall or at
SUNY Adirondack Saratoga.
Federal and State Financial Aid Acknowledgement and Permission Statement: I understand that financial aid (state and federal)
is only available to matriculated students. A matriculated student is a student who has been accepted to the College and is pursuing
a SUNY Adirondack degree. If I am a matriculated student who is eligible for financial aid and my financial aid is reduced or canceled for
any reason, I am responsible for all charges on my account. I give SUNY Adirondack permission to use any federal student aid (Pell
Grant, SEOG, Direct Loan) to pay any current charges that I incur for educational related activities and any other charges (institutional
and non-institutional) related to my attendance. I understand that at any time I may contact the Student Accounts (Bursar) Office to revoke
this permission regarding the use of my federal student aid.
My signature below indicates that I am in agreement with and/or acknowledge the statements above. I certify that the information provided
on this registration form is correct and that I have read all instructions and statements on this form and understand the implications and
requirements for registration at SUNY Adirondack. As noted previously, Non-Matriculated students are not eligible for federal or state
Financial Aid. Acceptance and acknowledgement of this Financial Responsibility Agreement is required in order to process registration.
Student Signature: ______________________________________________________________Date: ________________________
For Registrar Use Only: Banner ID Number: _________________________________________
If, prerequisite is not in Banner but is required for registration, what was submitted or reviewed:
High School Transcript College Transcript AP, CLEP, or IB Test Scores Placement Test Scores
Follow up communication sent via Mail or Email including Technology Guide Schedule/Bill Immunization (6+ in-person credits)
Additional Notes: Initials: ___________ Date: _________
Updated 12/10/2020
click to sign
signature
click to edit