Continuing Education Spring 2019

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Continuing Education Registration Form – Spring 2019
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 any Registrar’s Office listed below.
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 5/10/15evised 10/19/17