PERSONAL DATA
Student Name
LAST FIRST M FORMER
Student ID or Social Security # Program of Study
Address
STREET/PO BOX CITY STATE ZIP CODE
Email Address Phone
Semester: Fall Winter Spring Summer
STATISTICAL DATA
The following optional information is requested for data reporting purposes.
Have you ever taken a BCC credit course before? Yes No
Gender: Female Male Other
Date of Birth:
Please indicate if you are Hispanic/Latino: Yes No
Registration Form
(Please type or print)
Berkshire Community College ▪ 1350 West Street, Pittseld, MA 01201 ▪ www.berkshirecc.edu ▪ 413-236-1620 ▪ academic_advising@berkshirecc.edu
Please also select one or more of the following races:
American Indian/Alaskan Native
Asian
Black or African-American
Native Hawaiian or other Pacic Islander
White
Department Course Number Section Credits Audit Department Course Number Section Credits Audit
COURSES
Select the courses you wish to take and complete the following:
AUTHORIZATION
By signing below, you agree to abide by the rules and regulations of BCC and accept the courses indicated.
Student Signature
A
cademic Advising Signature
Notes
Date
Date
Acceptance
Date & Initials
Berkshire Community College is an afrmative action/equal opportunity institution and
does not discriminate on basis of race, creed, religion, color, gender, gender identity, sexual
orientation, age, disability, genetic information, maternity leave, military service, and national
origin in its education programs or employment.
White Copy: Registrar; Yellow Copy: Advisor; Pink Copy: Student
Total Credits:
R
evised 5/8/2020
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signature
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