Student Registration Form - Jefferson Community College Page 2
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2Student Registration Form
J_ _ _ _ _ _ _ _ _
Course Selections for term: ____________________
Primary Objective at JCC (choose one)
CRN
Course
Days
Times
Transfer to another SUNY college after earning a degree from JCC.
Transfer to a non-SUNY college after earning a degree from JCC.
Transfer to a SUNY college without earning a degree from JCC.
Transfer to a non-SUNY college without earning a degree from JCC.
Earn a degree/certificate from JCC and seek employment.
Learn new skills or upgrade existing skills without earning a degree.
Seek enrichment rather than pursue a degree/certificate from JCC.
Obtain a Certification of General Education Development (GED)
Uncertain
Other:________________
First Generation College Student Survey
Did either of your parents graduate from a college or university
Advisor Signature:
Date:
with a bachelor's (4-year) degree?
yes
no
Student Signature:
Date:
Did either of your parents graduate from a college or university
with an associate's (2-year) degree?
Incomplete registration forms may result in processing delays.
yes
no
Perkins Grant Program Survey
Census Data
New Students Only
Federal, state and local laws mandate that the information requested below be filled out completely
To comply with reporting requirements under the
to provide statistics for the federal and local agencies. These statistics impact college funding.
Perkins grant program, the College requests you
answer the following question. The information is
Military Affiliation
Disability
confidential, for reporting numerical statistics only.
Active-duty
Dependent of Veteran
None
The information is NOT used to determine eligibility
for admission, enrollment or registration.
Veteran
Spouse of Veteran
(1) Learning Disability
Are you unemployed or underemployed and
Spouse of active duty
Reservist
(2) Vision Impairment
Dependent of active duty
None
(2a) Vision Impairment- Legally Blind
experiencing difficulty in obtaining or upgrading
Plans for employment during the semester
employment?
(3) Hearing Impairment
yes
no
Not employed
(3a) Legally Deaf
If yes, please indicate if either of the following items
Employed full-time
(4) Chronic Illness
applies to you.
Employed part-time (20 hours or more)
(5) Mobility Impairment- No Device Needed
You have worked primarily without pay to care for a
Employed part-time (less than 20 hours)
(5a) Mobility Impaired- Wheelchair Needed
International Students
home and family and for that reason you have
(5b) Mobility Impaired- Other Device Needed
diminished marketable skills and you have been
Visa Type ___________________
(7) ADD/ADHD
dependent on the income of another family member
Country of Citizenship__________
(8) Psychological Disabilities
Language you feel most comfortable with
(9) Traumatic Brain Injury
but are no longer supported by such income.
yes
no
English
(10) Other Physical Impairment
You are a parent whose youngest dependent child
Spanish
(14) Asperger's
Other
(15) Autistic
will become eligible to receive assistance under
Part A of Title V of the Social Security Act not later
(16) Speech/Language Impairment
than two years after the date on which the parent
(17) Alcohol/Substance Abuse
applies for assistance under this Title.
Prefer Not to Answer
yes
no
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