REGISTRATION FORM
Please Print
Semester: Fall 20____ Spring 20____ Summer 20____
SCCC ID number Social Security Number (only if a new student)
Last Name First Name MI
Street Address City State Zip
Cell Phone Home Phone Work Phone Email Address
County Sex (M,F) Ethnicity Race Birth date Citizen
(see reverse for codes) (mm/dd/yy) (y, n)
Student Goals: Check the box next to the statement which most accurately reflects your current educational goal at SCCC:
□ 1. Transfer to another SUNY College after earning an SCCC degree/certificate □ 6. Learn new skills or upgrade existing skills without
□ 2. Transfer to a non-SUNY college after earning a degree/certificate at SCCC degree or certificate
□ 3.Transfer to another SUNY college without earning a degree/certificate at SCCC □ 7. Seek enrichment rather than pursue a degree or certificate
□ 4. Transfer to a non-SUNY college without earning a degree/certificate □ 8. Obsolete
□ 5. Earn a degree/certificate at SCCC and seek employment rather than □ 9.Uncertain
than pursue further post-secondary education
LIST HERE ALL OTHER COLLEGES ATTENDED:
COURSE SELECTION:
CRN DEPT Course# SEC DAYS/TIMES CR NOTES or SPECIAL APPROVAL
I understand that I am responsible for knowing and meeting all program requirements.
I understand that Schenectady County Community College (SCCC) uses a collection agency as a means of debt collection. If it becomes necessary to
submit my account for collection, I agree to be responsible for collection costs of up to 40% in addition to the principal debt. I further understand that
any information I have provided to SCCC may be used to assist in debt collection.
Student Signature__________________________________________ Date______________ Processed______
Advisor Signature__________________________________________ Date______________ Date__________
March 24, 2020
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