Hudson Valley Community College, 80 Vandenburgh Avenue, Troy, NY 12180-6096 (518) 629-4574
Student Record Information (SRI Form)
Social Security Number* __________________________________ Date of Birth ____________________
Name* _____________
Last First MI
Mailing Address _________________________________________________ ( Check here for change of address)
City _________________________________________ State __________ Zip Code _______________
Personal E-Mail __
_____________________________ Cell Phone _______________________________
Sex** Male Female Home Phone __
As required by SUNY System, all students must answer the following two questions:
Have you ever been convicted of a felony? . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . Yes No
Have you ever been dismissed from a college or university for disciplinary reasons? Yes No
Are you Hispanic/Latino?** No Yes
If yes, what is your background? (select one) Central American Dominican Mexican Puerto Rican
South American Other/Hispanic/Latino
All students, please indicate your race (select one or more)**
American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White Two or More Races Unknown
**NOTE: Hudson Valley Community College is required to furnish New York State with gender and ethnic data for every student.
What is your Home High School? ________________________________________________________
Expected Date of High School Graduation _________________________________________________
Semester/Year: Summer 2020 POT S8 - July 6 to August 14
Please list/write the course(s) you would like to enroll below:
Subject Code
Course #
Section #
Course Title
By entering my name below, request registration for the above course and hereby give permission to Hudson Valley Community College to
send my grades and transcripts to my high school guidance office.
tudent Name
uidance Counselor/High School Official Name for Approval
Please return form to the Registrar's Office at Hudson Valley Community College.
College in the High School Program
Failure to pay by the stated deadline will result in NOT receiving college credit for the course(s) listed
below. Please consult the Questions & Answers Brochure for appropriate payment deadlines.