Student Registration Form - Jefferson Community College
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1
2Student ID:
Student Registration Form
J _ _ _ _ _ _ _ _
High School Data: Please check one.
Registration Term:
I graduated from __________________________in _____.
High School
Year
Spring 20__
Summer 20__
Fall 20__
Winter 20__
The school city/state is:__________________________
I received a GED (equivalency Diploma) from the
Current Legal Name
Date of Birth
State of _____________________ in the year__________.
I am not a high school graduate or GED holder since
________________ ________________ ____
__ __ - __ __ - __ __ __ __
I am still enrolled at ______________________________
Last
First
MI
Month Day
Month Day
Year
Year
with an expected graduation date of ______________.
Previous Name (if applicable)
Email address
I am not a high school graduate or GED holder.
I was/am being homeschooled with a graduation date of
________________ ________________ ____
___________________________
_____________________________.
Last
First
MI
(month/Year)
Current Address
College Education History:
__________________________________________________
____________
New: I have never attended college.
Street
County
Continuing: I was in attendance at JCC last semester.
High School: I have attended or am attending JCC while
______________________
________
________
__ __ __ - __ __ __ - __ __ __ __
in high school.
City
State
Zip Code
Home Telephone Number
Returning: I have attended JCC in the past taking credit courses,
but I was not enrolled last term.
__ __ __ - __ __ __ - __ __ __ __
__ __ __ - __ __ __ - __ __ __ __
Transfer: I have never attended JCC, but I have attended a
Cell Phone Number
Business Telephone Number
degree-granting College/University: Enter data below.
Home of Record (If military)
Academic transcripts are required for all colleges which you have
_____________________________________________ ____________
attended or from which you have received (or will receive) credit.
Street
County
Attendance
Degree
____________________________ ________
________
College Name
City, State
Date
Earned
City
State
Zip Code
Citizenship
Student Social Security Number
U.S. Citizen
__ __ __- __ __- __ __ __ __
Resident Alien (green card)
This completed form may be faxed to:
315-786-2471
Refugee/Asylum
Hispanic Origin
Ethnicity
This completed form may be mailed to:
Advising, Career & Counseling Center
Non-Hispanic
White
Jefferson Community College
Dominican
Black or African American
1220 Coffeen Street
Mexican
Asian
Watertown, NY 13601
Puerto Rican
Native Hawaiian or Other Pacific Islander
This completed form may be emailed to: advising@sunyjefferson.edu
Central American
American Indian or Alaska Native
Questions? Call 315-786-2271
South American
Complete both sides of this form.
Gender
Cuban
Incomplete forms may result in processing delays.
Male
Female
Other/ Unknown
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