ROCKLAND COMMUNITY COLLEGE
STUDENT DATA FORM
Records & Registration
Non-Matriculated students enrolling PART-TIME must complete this form.(less than 12 credits)
First _____________________________________________ Middle ______________ Last _____________________________________
Preferred Name
___________________________________________ Former Last Name ________________________________________
Home/Street Address/Apt #
__________________________________________________________________________________________
City
___________________________________________________ State ______________________ Zip Code _____________________
Telephone: Home ( ______ )
_____________ Mobile # ( ______ ) _____________________ Work # ( ______ ) _______________________
SS # _____________________________________________ E-Mail _______________________________________________________
Date of Birth: Month ____ Day ____ Year ____
Gender: Woman ____ Man ____ Transgender ____ Other ____ Preferred Pronoun: She ____ He ____ Ze ____ None ____
Name of High School or State Issued HSE/GED:
_______________________________________ Date of Graduation or HSE/GED: _________
College Attended:
______________________________________________________________ Highest Degree Held: __________________
If your ethnic origin is Hispanic/Latino, please choose one of the following to best describe your background:
❑Dominican ❑Mexican ❑Puerto Rican ❑Central American ❑South American ❑Cuban
❑Asian
Please indicate your race by selecting one or more from the following:
❑ Black or African-American ❑ White
❑American Indian or Alaskan Native ❑Native Hawaiian or Other Pacific Islander
Have either of your parents graduated from a four-year college or university? oYes oNo
Are you a United States Citizen? ................................................................ ❑ Yes ❑ No
RESIDENCY
If no, are you a permanent resident of the US?
Has NY State been your legal residence for the past year?
......................................... ❑ Yes ❑ No
..................... ❑ Yes ❑ No
NY county of residence for the past 6 months:
_____________________________________________________________________
State of residence if other than New Y
ork: _________________________________________________________________________
To prove residency at the time of registration: • Students who are New York residents for the last twelve (12) months and Rockland County residents for the last six (6) months must
submit a photocopy of documentation (i.e., NYS driver’s license, income tax return, utility bill, phone bill, or bank statement). • Students who are New York residents for the last twelve
(12) months IN COUNTIES OTHER THAN ROCKLAND must submit a Certificate of Residency. Failure to present DATED documentation OR a Certificate of Residency will result in
a charge of out-of-state tuition (double in-state tuition).
FOREIGN STUDENT INFORMATION
Country of Citizenship: ______________________________________ Country of Birth: _____________________________________
Type of Visa or Status: ❑ F-1 (Student) ❑ B-Visa ❑ M-1 Visa ❑ J-1 (Exchange) ❑ Refugee
❑ Other _____________________________________________________________________________
Have you ever been dismissed from a college for disciplinary reasons?
❑ Yes ❑ No
OTHER INFORMATION
I understand that withholding information or giving false information may make me ineligible for admission to, or continuation at, the College.
Signature
______________________________________________________________ Date ____________________________________
Therefore, by submitting this information, I certify that it is true, correct and complete. In addition, I understand that upon my enrollment I must abide
by the policies and regulations of Rockland Community College.
I understand that I must file an Immunization Form/Response Form for Meningococcal Meningitis regardless of my age. I also understand that if I was born
on or after Jan. 1, 1957 and if I am enrolling in 6 or more credits I must provide proof of immunity against measles, mumps, and rubella. Failure to comply
will result in withdrawal, without refund, from all classes. I certify that all information submitted on this data sheet is true to the best of my knowledge.
Any deliberate falsification or omission of data may result in denial of registration or dismissal. I understand that registering as a Non-Matriculated
student prohibits me from being eligible for federal and state financial aid.
65/R/StudentDataForm/11-18
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