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Continuing Education Registration Form – Spring 2018

Last Name: ________________________First Name: ____________________________Middle Name: ___________________

The Personal Privacy Protection Law requires this notice to be provided when collecting personal information from individuals.The information on this registration

form will be used by the College to evaluate your request for registration and will be incorporated into your student records if/when you enroll.Failure to provide

the requested information could prevent your registration from being processed.The authority to request this information is found in Section 355(2)(h) of the NYS

Education Law.This registration form information will be maintained in the College Records Office and/or by the Office for Continuing Education, as appropriate.

The official(s) responsible for the maintenance of this information is the College Registrar and/or the Office for Continuing Education, Suffolk County Community

College, 533 College Road, Selden, NY 11784.Your Social Security Number is used to coordinate the collection of information for all your student records.Author-

ity to collect the Social Security Number is granted under Section 355 of the NewYork Education Law.The disclosure of your Social Security Number is voluntary

and you may refuse to provide this information.

Social Security #:_________________________________________________________________________________________

TERM: _____ Fall ______ Spring ______ Summer _______ Wintersession Year:_______________________________

Mailing Address: _________________________________________________________________________________________

City: ____________________________________________________ State: ____________ZIP: _________________________

Permanent Address

(address where you reside)

: ________________________________________________________________

City: ____________________________________________________ State: ____________ZIP: _________________________

County (if other than Suffolk): ________________ Home Phone: ( ) ____________ Cell Phone: ( ) _________________

High School Attended:_____________________________________________________________________________________

Date of Birth: Day _________________________ Month ________________________ Year ____________________________

Former Last Name: _______________________________________________________________________________________

Home Campus: ___________________________________________________ Email: _________________________________

A=Ammerman (Selden) E=Eastern (Riverhead) W=West (Michael J. Grant/Brentwood)

Gender/Ethnicity/Race

(these questions are for statistical purposes only.Your response is optional and does not affect your admission/registration.

You will be given another opportunity to provide this information after registration if you wish to do so)

:

Gender: _____________________ (F=Female / M=Male)

Are you Hispanic/Latino?

Yes

No

If Hispanic or Latino, please indicate your ethnicity (select one): Cuban

Dominican

Mexican

Puerto Rican

South American Central American

Other Hispanic/Latino

Race (select one or more): American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Background Information:

1. Have you ever been suspended from college for disciplinary reasons?

Yes

No

2. Have you been a legal resident of the State of New York for the past twelve (12) months?

Yes

No

3. Have you been a resident of the County of Suffolk for the past six (6) months?

Yes

No

4. Are you a citizen of the United States?

Yes

No

5. Are you a veteran of the United States Armed Forces?

Yes

No

Emergency Contact Information:

Last Name: _________________________________________ First Name:_________________________________________

Address:_________________________________________________________ Relationship:___________________________

Primary Phone: __________________

Home Work Cell Other

Secondary Phone: __________________

Home Work Cell Other

Course Selection:

CAMPUS

CRN #

SUBJECT

COURSE #

TUITION AND FEES

(A, E, W)

(ex. 91508)

(ex. ENG)

(ex. 101)

__________ ___________ _________________ _____________________________ ____________________________

__________ ___________ _________________ _____________________________ ____________________________

__________ ___________ _________________ _____________________________ ____________________________

__________ ___________ _________________ _____________________________ ____________________________

Form of Payment:

Check

Money Order

Amount Due $ _____________________________

Signature: ___________________________________________________________________ Date: __________________________

Mail this form to the Registrar’s Office at the campus where you are applying for courses.

Suffolk County Community College

Suffolk County Community College

Suffolk County Community College

Eastern Campus

Ammerman Campus

Michael J. Grant Campus

Registrar’s Office

Registrar’s Office

Registrar’s Office

121 Speonk-Riverhead Road

533 College Road

Crooked Hill Road

Riverhead, NY 11901

Selden, NY 11784

Brentwood, NY 11717

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For Office Use Only: (NEWNONM: SAAQUIK/SFAREGS)

Processed by: _____________________________________ Campus: _______________ Date:__________________Revised 5/10/15

evised 10/19/17