Spring Summer 2010 - SUNY Orange

SUNY ORANGECREDIT COURSE REGISTRATION FORMCreditRegistrationCircle Only One:FALL SPRING SUMMERRegistration Instructions:1. An activity fee of $5 per credit must be included when registering for part time credit courses and $68 per fulltime course load.2. A $9 insurance fee must be included with tuition payment for full time students and $2 for part time students.www.sunyorange.eduSTUDENT’S LAST FIRST MIDDLE INITIALA # __ __ __ __ __ __ __ __STUDENT’S LEGAL ADDRESS CITY STATE ZIP OTHER NAMES USEDLASTFIRSTSTUDENT’S LOCAL ADDRESS ( IF DIFFERENT)HOME ( ) BIRTH DATE (MANDATORY)CELL ( )WORK ( ) _____ / ______ / _______ALL - SELECT ONE OR MORE: 01 WHITE 02 BLACK 04 ASIAN 05 AMERICAN INDIAN / NATIVE ALASKAN 08 NATIVE HAWAIIAN / PACIFICISLANDER(NOTE: DUE TO NEW GOVERNMENTAL REPORTING REQUIREMENTS, PERSONS WHO AREHISPANIC/LATINO MUST RESPOND TO THE ABOVE AND THEN COMPLETE THEFOLLOWING SECTION BELOW)-----------------------------------------------------------------------------------------------------------------------------------------ALL - ETHNICITY: ARE YOU HISPANIC / LATINO? YES NOIF YES, IS YOUR BACKGROUND? (YOU MUST SELECT ONLY ONE, IF HISPANIC/LATINO) : CENTRAL AMERICAN DOMINICAN MEXICANPUERTO RICAN SOUTH AMERICAN OTHER HISPANIC/LATINONY COUNTY (OR STATE) OF LEGALRESIDENCYSOCIAL SECURITY # (OPTIONAL)SEX MALE FEMALECITIZEN OF U.S. YES NOIF NO WHAT COUNTRY?____________ARE YOU A HIGH SCHOOL GRAD ORRECIPIENT OF A GED?YES NONAME OF HIGH SCHOOLIN CASE OF EMERGENCY, CONTACT (GIVE NAME) HOME ( )CELL ( )WORK ( )NAME OF OTHER COLLEGES ATTENDED ( UP TO 2)TODAY’S DATE ____/____/_____ TERM KEYNEW STUDENT ___ YES ___NO FA FALLSP SPRINGTERM OF LAST REGISTRATION SU SUMMERCRN COURSE NUMBER SECT/LEC LAB CREDSFALL ____ SPRING____ SUMMER ____I understand how the selected course(s) relate to my academic program orhow they meet my academic goals.I acknowledge financial responsibility for the selected course(s) if theyare not cancelled or if I do not withdraw prior to the start of the semestereven if I do not attend these classes.I understand that if immunization requirements are not met, I may beDropped from my classes._________________________________________ ____/____/_____STUDENT’S SIGNATURE DATE_________________________________________ ____/____/_____ADVISOR’S SIGNATURE (if applicable)DATECreditsMake checks payable to: Orange County Community CollegeIf using a Credit Card __ MC __ Visa __ Discover ___________ Exp. Date ____/_____Print name on Credit Card if not Student _____________________________________