Hudson Valley Community College, 80 Vandenburgh Avenue, Troy, NY 12180-6096 (518) 629-4574 www.hvcc.edu
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:
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.
S
tudent Name
Date
G
uidance Counselor/High School Official Name for Approval
Date
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.
*HVCC is required by federal law/regulations to collect your social security number (SSN) or individual taxpayer identification number (ITIN) to file
information returns with the IRS and to furnish a statement to you. In addition, your name on file with the College must match your name as filed with the
Social Security Administration. PENALTY: If you fail to furnish your correct SSN or ITIN to the College, you may be subject to a penalty levied by the IRS.
