vrcc m ity HIGH SCHOOL PROGRAM College ROCKLAND COMMUNITY COLLEGE CERTIFICATION FORM

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2 vrcc m ity College l. STATE UNIVERSITY OF NEW YORK ROCKLAND COMMUNITY COLLEGE HIGH SCHOOL PROGRAM CERTIFICATION FORM Last Name First Name Social Security Number Date of Birt,, _ High School Current Grade Level Check One: Course(s) will be taken at the high school Course(s) will be taken on Rockland Community College Campus in Suffern or the Haverstraw Center PRINCIPAL CERTIFICATION & COURSE LIST REQUIRED FOR COURSES TAKEN ON RCC'S CAMPUS OR AT THE HAVERSTRAW CENTER TO BE COMPLETED BY THE STUDENT: I have read, understood and agreed with the requirements, limitations and procedures of the Rockland Community College High School Program (RCCHSP). I also understand that registration in the RCCHSP will create a permanent academic history and transcript at Rockland Community College. I agree that RCC may release my transcript to my high school without my written permission until I have graduated from high school. I also understand and agree that RCC reserves the right to notify my parents and high school if I become involved in any incident requiring disciplinary action. Student Signature Oat TO BE COMPLETED BY THE PARENT OR GUARDIAN: As the parent or guardian of the RCCHSP student, I too have read, understood and agreed with the requirements, limitations and procedures of the Rockland Community College High School Program (RCCHSP). I also understand and agree with the creation of a permanent academic history and transcript at RCC for my child, the release of my child's transcript to the high school until my child's graduation, and the right of the College to notify me if my child becomes involved in any incident requiring disciplinary action. I also understand that some courses may deal with adult content subject matter. Furthermore, I accept full responsibility for all tuition and fees that result from my child's registration in courses through the RCCHSP. Parent or Guardian's Name (Please Print) Parent or Guardian's Signature Date

3 ROCKLAND COMMUNITY COLLEGE STUDENT DATA FORM Records & Registration Non-Matriculated students enrolling PART-TIME (less than 12 credits) must complete this form. First Middle Last Preferred Name Former Last Name Home/Street Address/Apt # City State Zip Code Telephone: Home ( ) Mobile # ( ) Work # ( ) SS # Date of Birth: Month Day Year Gender: Woman Man Transgender Other Preferred Pronoun: She He Ze None Name of High School or State Issued HSE/GED: College Attended: Date of Graduation or HSE/GED: Highest Degree Held: If your ethnic origin is Hispanic/Latino, please choose one of the following to best describe your background: Dominican Mexican Puerto Rican Central American South American Cuban Please indicate your race by selecting one or more from the following: Asian Black or African-American White American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Have either of your parents graduated from a four-year college or university? o Yes o No RESIDENCY Are you a United States Citizen?... Yes No If no, are you a permanent resident of the US?... Yes No Has NY State been your legal residence for the past year?... Yes No NY county of residence for the past 6 months: State of residence if other than New York: To prove residency at the time of registration: Students who are New York residents for the last twelve (12) months and Rockland County residents for the last six (6) months must submit a photocopy of documentation (i.e., NYS driver s license, income tax return, utility bill, phone bill, or bank statement). Students who are New York residents for the last twelve (12) months IN COUNTIES OTHER THAN ROCKLAND must submit a Certificate of Residency. Failure to present DATED documentation OR a Certificate of Residency will result in a charge of out-of-state tuition (double in-state tuition). FOREIGN STUDENT INFORMATION Country of Citizenship: Country of Birth: Type of Visa or Status: F-1 (Student) B-Visa M-1 Visa J-1 (Exchange) Refugee Other OTHER INFORMATION Have you ever been dismissed from a college for disciplinary reasons? Yes No I understand that withholding information or giving false information may make me ineligible for admission to, or continuation at, the College. Therefore, by submitting this information, I certify that it is true, correct and complete. In addition, I understand that upon my enrollment I must abide by the policies and regulations of Rockland Community College. I understand that I must file an Immunization Form/Response Form for Meningococcal Meningitis regardless of my age. I also understand that if I was born on or after Jan. 1, 1957 and if I am enrolling in 6 or more credits I must provide proof of immunity against measles, mumps, and rubella. Failure to comply will result in withdrawal, without refund, from all classes. I certify that all information submitted on this data sheet is true to the best of my knowledge. Any deliberate falsification or omission of data may result in denial of registration or dismissal. I understand that registering as a Non-Matriculated student prohibits me from being eligible for federal and state financial aid. Signature Date 65/R/StudentDataForm/11-18

4 Request for Waiver of the Placement Test (Early Admit and GED Applicants must take the Placement Test) Name Address City State Zip Phone SSN or RCC ID # Note: Attach a copy of your unofficial transcript or SAT/ACT score report. (Official copies must be sent to Admissions). Submit this completed form to: Placement & Assessment, Rm 8340, 145 College Rd, Suffern NY or fax to: You will be granted a waiver from one or both portions of the placement test, if you meet any of the following criteria. Test scores are valid for three years from the test date. Please check the waiver condition that applies: English r SAT: Critical Reading score of 480 or higher or Evidence-Based Reading and Writing score of 480 or higher r ACT: English score of 20 or higher r NYS Regents: English score of 75 or higher Math r SAT: Math score of 570 or higher r ACT: Math score of 23 or higher r NYS Regents: Algebra II score of 85 or higher r 80 or higher in a high school Calculus course r 85 or higher in a high school Pre-Calculus course Allow three (3) business days for the processing of this request. Signature Date 145 College Road Suffern, NY /A&P/waiverform/2-17

5 Accessibility Services Technology Center, Room Semester of Enrollment (circle one) Fall Spring Summer Winter, 20 ASSESSMENT EXAM ACCOMMODATION REQUEST FORM NAME: Student ID #: ADDRESS: City State Zip Code: Phone # Cell: Emergency Contact: Phone # Are you applying to the RCC High School Program? Yes No Please indicate your High School Name Graduation Date / / Type of HS Degree: HS Diploma GED IEP Diploma PLEASE SELECT REQUESTED ACCOMMODATION Extended Time on Writing Subsection Assistive Technology: Enlarged Text Other Student Signature Date: / / All accommodation requests must be supported by your disability documentation on file with Accessibility Services. College policy requires that a qualified professional provide current and comprehensive documentation. A qualified professional includes a psychologist, medical doctor or other qualified healthcare professional. PLEASE RETURN REQUESTS ALONG WITH COMPLETE DOCUMENTATION TO: Accessibility Services Technology Center, Room 8150 Rockland Community College 145 College Road, Suffern, New York Fax: Revised 3/25/14