Summer 2023 Global Classroom High School

Student Record Information (SRI Form)

*NOTE: HVCC is awarding scholarships up to 8 credits to all students in Global High School Program sections for Summer 2023.
A student will be considered enrolled upon submission of this form. Students residing in the United States must also submit a
certificate of residence in order to enroll. Students should review the Summer 2023 Registration Calendar for deadlines
pertaining to drops, withdrawals & Refunds.

U.S. Issued Social Security Number*: Date of Birth:

Legal Name*: __________________________ _________________________ _____________________________________
First Name (Given) Middle Name Last Name (Family)
*HVCC is required by federal law/regulations to collect your social security number (SSN) or correct individual taxpayer identification number (ITIN) to file information returns with the IRS and to
furnish a statement to you. In addition, your name on file with the College must match your name as filed with the Social Security Administration. PENALTY: if you fail to furnish your correct SSN
or ITIN to the College, you may be subject to a penalty levied by the IRS.

□ Preferred/Chosen First Name: _________________________________________________________________

(Please print preferred/chosen first name)

Legal Sex **: ☐ Male or ☐ Female Optional: Gender Identity**: ☐ Male ☐ Female ☐ Non-Binary
Any student who uses a name other than the legal first name or identifies with a gender other than the legal sex may report the preferred/chosen first name and/or gender identity on this
registration form. Your preferred/chosen name will be used in place of your legal name for internal communication and certain external communications. Examples of internal communications
include, but may not be limited to class rosters, advising lists, and e-mails. Please note, for federal reporting purposes, individuals are required to report legal sex as either male or female.

Home Physical Address: (Check here for change of address)

City: Province: Postal Code:

Country: Personal Email:

Mobile Phone: +
Country Code Area/City Code Phone Number

Home Phone: +
Country Code Area/City Code Phone Number

As required by SUNY System, all students must answer the following two questions:
1) Have you ever been convicted of a felony? . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . Yes No
2) Have you ever been dismissed from a college or university for disciplinary reasons? Yes No
Are you Hispanic/Latino?** . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If yes, what is your background? (select one) Central American Dominican Mexican Puerto Rican
South American Other/Hispanic/Latino
All students, please indicate your race (select one or more)**
American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander
White Two or More Races Unknown
Hudson Valley Community College is required to furnish New York State with gender and ethnic data for every student.

Name of Home High School: Expected Date of High School Graduation:

Please list/type the course(s) you would like to enroll below:

Subject Code Course # Course Title Start Date End Date Pathway

By entering my name below, I request registration for the above course and hereby give permission to Hudson Valley Community College to send my
grades and transcripts to my high school officials. After completion, forward to your high school official for approval.
Student Name (Required): ________________________________________________________________________ Date: _______________________

High School Official Name (Required): _________________________________________________________________ Date: _______________________

Please return this completed form to the Registrar’s Office via email at [email protected].
HVCC Registrar's Office Processing: Add GCHP attribute to SGASADD.
Subject Subject Code Course # Course Title Credits Start Date End Date Pathway
Accounting ACTG 110 Financial Accounting 4 7/3/2023 8/10/2023 Business
Accounting ACTG 120 Personal Finance 3 7/3/2023 8/10/2023 Business
Biology BIOL 104 Topics in Biology - the Environment 3 7/3/2023 8/10/2023 STEM
Biology BIOL 128 Sports Nutrition 3 7/3/2023 8/10/2023 STEM
Biology BIOL 115 Medical Terminology 3 7/3/2023 8/10/2023 Health
Biology BIOL 125 Nutrition 3 7/3/2023 8/10/2023 Health
Business Administration BADM 100 Business Concepts & Applications 3 7/3/2023 8/10/2023 Business
Business Administration BADM 110 Legal & Ethical Environment of Business I 3 7/3/2023 8/10/2023 Business
Civil Engineering CIVL 110 Engineering Graphics 3 7/3/2023 8/10/2023 STEM
Computer Information Systems CISS 100 Introduction to Computing & Information Science 3 7/3/2023 8/10/2023 STEM
Computer Information Systems CISS 109 Python Programming 4 7/3/2023 8/10/2023 STEM
Computer Information Systems CISS 110 Programming and Logic I 4 7/3/2023 8/10/2023 STEM
Computer Information Systems CISS 125 Computer and Information Security 3 7/3/2023 8/10/2023 STEM
Criminal Justice CRJS 101 Introduction to Criminal Justice 3 7/3/2023 8/10/2023 Law
Criminal Justice CRJS 110 Introduction to Criminal Law 3 7/3/2023 8/10/2023 Law
Economics ECON 100 Principles of Macroeconomics 3 7/3/2023 8/10/2023 Business
Economics ECON 101 Principles of Microeconomics 3 7/3/2023 8/10/2023 Business
Education EDUC 100 Child Development 3 7/3/2023 8/10/2023 Education
Education EDUC 110 Foundations of Education in America 3 7/3/2023 8/10/2023 Education
Electronics ELET 100 Electricity I 4 7/3/2023 8/10/2023 STEM
Electronics ELET 120 PC Hardware Essentials 3 7/3/2023 8/10/2023 STEM
Electronics ELET 210 Digital Electronics 4 7/3/2023 8/10/2023 STEM
English ENGL 101 English Composition I 3 7/3/2023 8/10/2023 Humanities
English ENGL 115 Library Skills for Research 1 7/3/2023 8/10/2023
Exercise Studies EXER 101 Introduction to Exercise Science 3 7/3/2023 8/10/2023 Health
Fine Arts ARTS 100 Survey of Art History I 3 7/3/2023 8/10/2023 Humanities
Fine Arts ARTS 104 History of Fashion 3 7/3/2023 8/10/2023 Humanities
Health HLTH 130 Creating Healthy Relationships 3 7/3/2023 8/10/2023 Health
Health HLTH 131 Stress and Health 3 7/3/2023 8/10/2023 Health
Health HLTH 140 Intervention and Prevention 3 7/3/2023 8/10/2023 Health
Health HLTH 160 Personal & Community Health 3 7/3/2023 8/10/2023 Health
History HIST 100 Western Civ & the World I 3 7/3/2023 8/10/2023 Humanities
Human Services HUSV 105 Human Development & the Family 3 7/3/2023 8/10/2023 Humanities
Marketing MKTG 120 Principles of Marketing 3 7/3/2023 8/10/2023 Business
Music MUSC 110 Music in Workld Cultures 3 7/3/2023 8/10/2023 Humanities
Philosophy PHIL 100 Introduction to Philosophy 3 7/3/2023 8/10/2023 Humanities
Physics PHYS 105 Introduction to Astronomy 3 7/3/2023 8/10/2023 STEM
Political Science POLS 100 Introduction to Political Science 3 7/3/2023 8/10/2023 Humanities
Political Science POLS 105 American National Government 3 7/3/2023 8/10/2023 Humanities
Psychology PSYC 100 General Psychology 3 7/3/2023 8/10/2023 Humanities
Sociology SOCL 100 Sociology 3 7/3/2023 8/10/2023 Humanities
Sociology SOCL 110 Social Problems 3 7/3/2023 8/10/2023 Humanities
 ACKNOWLEDGEMENT/REFUSAL TO PROVIDE
SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
Registrar’s Office ■ 80 Vandenburgh Ave, Troy, NY 12180 ■ www.hvcc.edu

Regulations set forth by the Internal Revenue Service (IRS) require the College to collect and verify the
U.S. Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN) for every
student in order to file information returns with the IRS and to furnish a statement to you (IRS Form
1098T). You, or the person who claims you as a dependent, may be entitled to a tax credit. In addition,
please be aware that failure to provide your correct SSN or ITIN may result in a fine by the IRS.

If you wish not to provide your SSN or ITIN to the College, please complete the information below
and return this form as an attachment to a message sent from your Hudson Valley student e-mail
account.

I acknowledge the above referenced statement and the College’s legal obligation to collect my SSN
or ITIN for IRS reporting purposes. I also acknowledge that I could be subject to penalties from the
IRS if I refuse to disclose my SSN or ITIN. Despite these legal obligations, I do not wish to provide
my SSN or ITIN to Hudson Valley Community College. By entering your name below, you
are indicating acknowledgement of the above.

Name __________________________________________________ Date _______________________

Please Type Name

Signature _________________________________________ Date of Birth _______________________

College use only: ⧠ Hold removed ⧠ Attribute Date _______________ Initials ____________