Fillable Office of Records and Registration Registration Form for (Adirondack Community College)

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Office of Records and Registration Registration Form for (Adirondack Community College)

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Office of Records and Registration
640 Bay Road, Queensbury, NY 12804-1445
CALL: 518.743.2279 | FAX: 518.832.7601 | EMAIL: registrar@sunyacc.edu
Page 1 of 2 Updated 7/15/19
Registration Form for Non-Matriculated Students
General Non-Matriculation Rules:
Non-matriculated students may attend on a part-time basis only and can earn a maximum of 18 credit hours prior to matriculation. Non-
matriculated students are not eligible to receive financial aid. Non-Matriculated Students receive grades and GPA calculations but do not
receive an academic standing or academic honors.
Registration Requirements:
1. Registration Form: Complete all requested information. Incomplete registration forms cannot be processed.
2. Proof of Identification: Individuals looking to register must provide proof of identification when submitting this form.
Forms of identification include; Government Issued ID, Marriage License, Social Security Card, or Court Order.
3. Proof of prerequisites: Students enrolling in courses with prerequisites (available in the College Catalog) are required to show proof
of prerequisites by submitting an unofficial transcripts or completing Placement Testing.
4. Proof of Immunizations: NYS Public Health Law and College policy can be found in the College catalog.
5. Submitting Forms: Completed forms and required documentation should be emailed, mailed, or faxed to the Office of Records and
Registration at the contact information noted above with required form of identification included or attached.
General Person Information
Semester: ❑ Summer ❑ Fall ❑ Winter ❑ Spring Year: ____________
Student Type (Select One):
❑ Student with previous SUNY Adirondack credit or Continuing Education Registration.
❑ Student without SUNY Adirondack Credit or Continuing Education Registration.
Student Name (Please print): _____________________________________________________________________________________
First Middle Last
Former Name (Please print): ______________________________________________________________________________________
Identification listed above is required to make changes to the student’s legal name on all College records. Legal names must be provided.
Social Security Number or Banner ID (former students): _______________________________________________________________
Date of Birth (mm/dd/yy): _____________________________________
Sex: ❑ Male ❑ Female
Permanent Address: _____________________________________________________________________________________
Street City State Zip
If you are a NYS resident, you must submit a Certificate of Residency to Student Accounts within 60 days of the beginning of the semester.
Phone (including area code): _____________________________ ❑ This is a Cell Phone ❑ This is not a Cell Phone
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 you are a non-citizen, we will require a copy of your visa.
*If no, are you a permanent resident? ❑ Yes ❑ No
If you are a permanent resident and listed a social security number, you must submit a copy of your social security card.
Visa Type: ______________________________________ Nation of Birth/Citizen: ______________________________
Foreign Students Only: ________________________________________________________________________________________
Please provide a permanent mailing address with postal code.
Race (check one or more): ❑ American Indian or Alaskan Native ❑ Asian ❑ Black or African American
❑ Native Hawaiian or Other Pacific Islander ❑ White
Are you Hispanic/Latino? ❑ Yes* ❑ No
*If yes, what is your ethnic background? ❑ Dominican ❑ Puerto Rican ❑ Mexican
❑ South American ❑ Central American ❑Other Hispanic/Latino
Emergency Contact Information Emergency Contact Name (Please Print): _____________________________________________
Relationship to Student: ________________________ Emergency Contact Phone #: _________________________________
Page 2 of 2 Updated 7/15/19
Education Information
Name of High School: _________________________________________________ Year Graduated: _____________
GED/TASC Date Completed: ___________________________________________
Other Colleges Attended or Currently Attending: ___________________________________________________________________
Have you ever been dismissed and/or suspended from a college for disciplinary (non-academic) reasons? ❑ Yes ❑ No
Requested Courses (11 credits maximum per semester, with a maximum of 18 credit hours earned prior to matriculation.)
CRN (Required)
Subject and Course 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.
I also understand that if my financial aid is reduced or canceled, I am responsible for all charges on my account. 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
(http://www.sunyacc.edu/refund-policy). 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
the Wilton Center.
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. Acceptance and acknowledgement of this
Financial Responsibility Agreement is required in order to process your course registration.
Student Signature: ____________________________________________________ Date: _____________________________
For Registrar Use Only: Banner ID Number: _____________________________ Initials: _________ Date: __________
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
☐ Other: __________________________________________________________________________________________________________
*Unofficial transcripts are all that is required for non-matriculated student registration.
Follow-up communication Sent via ❑Mail or ❑Email including;
❑ Technology Guide ❑Schedule ❑Bill ❑ Student Immunization Record Form ❑ Meningitis Response Form
Additional Notes or Communications with Student:
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Office of Records and Registration Registration Form for (Adirondack Community College)

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Completed 20 September 2020

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