Part-Time Student Registration Form

Early College High School

Part-Time Student Registration Form

Instructions: Students will be considered officially registered upon receipt of this form. Please fill out all fields completely. Both student and parent/guardian must sign & date at bottom. Completed Registration Forms must be submitted to the SUNY Canton Provost Officeno later than 4:00 pm on the second class day of the semester.

Term/Semester / Fall Spring / Year
SECTION A: PROGRAM INFORMATION
High School Campus / Brasher Falls CS Canton CS Carthage CS Clifton Fine CS Colton-Pierrepont CS Edwards-Knox CS Gouverneur CS Hammond CS Harrisville CS
Hermon-DeKalb CS Heuvelton CS Lisbon CS Madrid-Waddington CS Massena CS (MAS) Morristown CS Norwood-Norfolk CS Ogdensburg CS (8)
Parishville-Hopkinton-CS Potsdam CS Jefferson County School: ______
St. Lawrence-Lewis BOCES CTE Center(if applicable) / Northwest CTE (Ogdensburg) Seaway CTE (Norwood) Southwest CTE (Fowler) / CTE Program (if applicable)
Program Enrollment(select one) / XDual Enrollment(DUAL)
SECTION B: STUDENT INFORMATION
Last Name / First Name / Middle Name
Street Address / City / State / Zip / County
Phone / () / E-mail / E-mail Type / Student Parent/Guardian Other:
Social Security # (Required) / DOB (Required) / Gender / Female Male / Grade Level / 9 10 11 12 13
Ethnic Code / American Indian/Alaskan Native Asian (Non-Hispanic Origin) Black/African American (Non-Hispanic Origin) Hispanic/Latino
Native Hawaiian/Pacific Islander (Non-Hispanic Origin) White (Non-Hispanic/Origin) Two or more Races (Non-Hispanic Origin) Non-Resident Alien
Are you a Foreign Exchange Student? / No Yes / Do you wish your name, address & phone # to be listed in the Online Student Directory at SUNY Canton? / No Yes
Have you ever taken a course offered at SUNY Canton? / Semester / Year
Fall Winter Spring Summer
No Yes- If yes, please indicate last semester/year attended:
SECTION C: COURSE REGISTRATION & FEES
INSTRUCTIONS: Add information in the table below for each course in which you are electing to enroll. Add tuition & fees for selected courses in the totals line at bottom. See the current Course Offerings list for your district program (BOCES Distance Learning or Dual Enrollment) for a detailed list of courses and associated tuition/fees, or contact your High School Guidance Counselor. (NOTE: Tuition & fees are subject to change.)
CRN# / Course # / Course Name / Cr / Tuition / Tech Fee / College Fee / Total Cost
AREA 210 / Sustainable Building / 3 / $165.00 / $38.25 / $2.55 / $205.80
Subtotal: / 205.80
Transcript Fee / $5.00
TOTAL / $210.80
SECTION D: REGISTRATION CERTIFICATION
I certify that this form with my signature will constitute my registration at SUNY Canton College of Technology for the semester indicated at the top of this form. Tuition charges will be based on my student status as a part-time student enrolling in credit hours as indicated on the form above. Furthermore, my registration for this semester will continue until such time that I officially withdraw from college. I fully understand non-attendance does not constitute official withdrawal (see the current SUNY Canton Academic Catalog (www. ) for detailed information). I also understand that SUNY Canton deadlines and policies related to registration, enrollment and tuition also apply.
Student Signature / Date / Parent/Guardian Signature / Date

Please Submit Completed Forms To:

SUNY Canton Provost Office, Attn. Erin – 34 Cornell Dr., MAC 614, Canton, NY 13617 • p 315.386.7838 • f 315.386-7945 •

Updated 11/18/13