Enrollment Confirmation

Full Name

Date

Street Address

City

State

Zip

County

Cell Phone

Home Phone

Birth Date

Are you a US Citizen?

Yes
No

If yes, enter your social security #

If no, country of origin

Religion

Gender

Do you consider yourself Hispanic/Latino?

Yes
No

In addition, select one or more of the following racial categories to describe yourself

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White

Recovery Email (Non MSMC)

Marital Status

Single
Married

Choose all that apply

Student Type

Traditional
Graduate
Accelerated
Returning
Transfer
Visiting

If returning, last date attended

If transfer, have credits been evaluated?

Yes
No

Major (NOT EDUCATION)

Concentration (if any)

Education Certification

Yes
No

Certification Area

Childhood
Childhood/Special
Childhood/Middle School Ext
Adolescence
Adolescence/Special
Adolescence/Middle School Ext

Nursing students only, are you a

RN
LPN
None

NYS Public Law 2165 requires students to be immunized for Measles, Mumps, and Rubella. Also, NYS Public Law 2167 requires students to submit a Meningitis Notification Form. Students not in compliance 30 days after attending the first class will be DISMISSED (May not return during current semester). All documentation should be submitted to Health Services, 330 Powell Ave., Newburgh, NY 12550.

I certify that I am aware of this requirement

Please type your first and last name

Today's Date (MM/dd/yy)

I understand that electronically signing this form constitutes a legal signature agreeing to the terms and conditions and also certify that the provided information is complete, truthful, and accurate.