Office of Extended Programs 696 US Route 9, Wilton, NY 12831 CALL: 518.584.3959 | FAX: 518.584.0896 | EMAIL: academy@sunyacc.edu You may either print and fill this application out by hand or download it and fill it in on your computer.

To fill it out on your computer:

1. Begin by saving a copy of this application to your computer. We suggest using your last name as part of the file name to differentiate your application from the blank template. Be sure to save the file in a location (folder) on your computer that will be easy to find. 2. Close your web browser prior to filling in the application. 3. Open the saved file to begin completing the application. It is recommended that you enter your school and name, save the document and reopen it to ensure that the version of the program you are using is functioning correctly. 4. Complete the application by typing your information in the fields. Certain areas of the form contain check boxes or buttons; Simply click your mouse in the box/button you wish to choose. Remember to SAVE often.

Completed Forms should be sent to:  Upload to our secure website at www.sunyacc.edu/collegeacademy (PREFERRED)  SUNY Adirondack, Office of Extended Programs, 696 US Route 9, Bay Road, Wilton, NY 12831  Fax: 518-584-0896 COLLEGE in the HIGH SCHOOL COURSES: Please send completed forms back to your counselor

Registration Information . Complete all information included on this registration form. Incomplete registration forms cannot be processed. . Students enrolled in College Academy coursework are considered Non-Matriculated Students. . Students wishing to continue at SUNY Adirondack after they have completed High School, must apply and be accepted to the College at that time. . College Academy students receive grades and GPA calculations but do not receive an academic standing or academic honors.

Registration Form for College Academy Non-Matriculated High School and Home Schooled Students

Semester: ❑ Summer ❑ Fall ❑ Spring Year: ______General Person Information Student Type (Select One): ❑ Student currently or previously enrolled in SUNY Adirondack credit courses or Continuing Education programs. ❑ Student currently enrolled in the Early College Career Academy program through WSWHE BOCES. ❑ Student without SUNY Adirondack Credit or Continuing Education Registration. Registration Request Type (Select One): ❑ High School Academy: Student enrolled in SUNY Adirondack courses offered exclusively for high school students at the high school or online. College tuition is discounted for courses offered in the high school. ❑ Campus Academy: Student enrolled in SUNY Adirondack courses offered on the Queensbury campus, Wilton Extension Center, or online with full-time or part-time matriculated College students. Standard College tuition and fee rates apply. Student Name (Please print): ______First Middle Last Social Security Number or Banner ID (former students): ______Date of Birth (mm/dd/yy): ______Sex: ❑ Male ❑ Female Permanent Address: ______Street City State Zip New York State residents, must submit a Certificate of Residency to the Student Accounts office within 60 days of the beginning of the semester.

Page 1 of 3 Updated 7/7/2020 Cell Phone (including area code): ______Other Phone: ______Email Address: ______We will be sending follow up communications to this address. Please provide a personal email you check regularly.

Citizen, Race, and Ethnicity Information Are you a US citizen? ❑ Yes ❑ No If no, are you a permanent resident? ❑ Yes ❑ No If you are a non-citizen, we will require a copy of your visa. If you are a permanent resident and listed a social security number, you must submit a copy of your social security card.

Visa Type: ______Nation of Birth/Citizen: ______Race (check one or more): ❑ American Indian or Alaskan Native ❑ Asian ❑ Black or African American ❑ Native Hawaiian or Other Pacific Islander ❑ White Are you Hispanic/Latino? ❑ Yes ❑ No If yes, what is your ethnic background? ❑ Dominican ❑ Puerto Rican ❑ Mexican ❑ South American ❑ Central American ❑Other Hispanic/Latino Education Information Name of High School: ______Anticipated Date of Graduation: ______Current Grade Level: ❑ Freshmen (9) ❑ Sophomore (10) ❑Junior (11) ❑Senior (12) Emergency Contact Name: ______Phone #:______

Consult with your High School Counselor and list courses you wish to register for below: All course information below is required in order to process the registration request CRN Subject and Course Number Credits HS, Online or ADK Campus Days Time EXAMPLE: 12345 BUS 999 3 HS

Statement of Financial Responsibility, Registration Verification, Student and Parent/Guardian Acknowledgment By registering for classes at SUNY Adirondack, I acknowledge and agree that I am financially responsible for all charges related to my registration and housing. I understand that if financial payment and/or arrangements have not been made by the due date, the College reserves the right to remove me as a student for non-payment, deny me access to my registered classes, and/or place a "hold" on my student records restricting me from registering and/or obtaining a transcript until the account is paid in full. I am responsible for all late charges incurred. Failure to attend classes does not absolve me from financial liability. In all cases it is my responsibility to drop classes by the published drop/add date(s) and I accept financial liability for these classes in accordance with the SUNY Adirondack Bill Adjustment/Liability Schedule (http://www.sunyacc.edu/refund-policy). SUNY Adirondack may call (personally or automated) or text any phone number that I have provided to the College and leave a message regarding any outstanding account I have. I understand that, if the College texts me, I will be able to opt out. The College may use a collection agency or take legal action for any account balance due and I will be responsible for all charges owed which may include collection and/or litigation costs or attorney fees. I understand that the College will (1) electronically post my 1098-T form (Tuition Statement) to my Banner account so I can download the form for tax purposes and (2) mail a paper copy of my 1098-T to my primary address on file. I understand that I am responsible for providing the College with updated contact information either through Banner or in person at the Registrar's Office in Warren Hall or at the Wilton Center.

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My signature below indicates that I am in agreement with and/or acknowledge the statements above. I certify that the information provided on this registration form is correct and that I have read all instructions and statements on this form and understand the implications and requirements for registration at SUNY Adirondack. Acceptance and acknowledgement of this Financial Responsibility Agreement is required in order to process your course registration.

Student Signature: ______Date: ______Parent/Guardian Signature: ______Date: ______Parent/Guardian Printed Name: ______School Counselor Approval: I hereby certify that this student meets the minimum requirements of Junior Status and an 80 High School Grade Point Average to participate in SUNY Adirondack’s College Academy program selected. Counselor Signature: ______Date: ______Printed Name: ______School Phone Number: ______Counselor Email Address: ______College Official Approval: College Official Signature: ______Title: ______

Printed Name: ______Date Registration Form Received: ______

For Registrar Use Only: Banner ID Number: ______Initials: ______Date Processed: ______

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