Participant Information Form

Course*Please include the full name of the course.

Date Course Begins*Enter the dates of the course you selected

where course meets

In-Person at SUNY CCC location

In-Person at non-college location

Virtually (Zoom) or online

Where does your selected course meet?

Legal Name (First, MI, Last)*What is your legal name?

When completing the application we recommend that you use your legal name to ensure accurate and timely processing of required documents.

Chosen Name Note: To use your chosen name, once you are a student at SUNY Corning Community College, follow the instructions at: Chosen Name page

Former NameIf you have SUNY CCC educational records under a different name, please give former name.

Street Address*what is your physical address?

City*what city/town do you live in?

State*what state do you live in?

ZIP Code*what is your 5-digit ZIP code?

Cell Phone Number*what is your cell/mobile number?

Text Permission

I give permission for the college to text me with important information related to my attendance

Work Phone NumberDo you have a work phone number?

Email*What is your email address?

EmployerPlease indicate your employer for our records. We will not contact your employer.

Please list your employer for our records. We will not contact your employer without your permission.

Date of Birth*What is your official date of birth?

Gender*

Female

Male

Non-Binary

Are you a US citizen?*

Yes

No

Are you a citizen of the United States of America?

If no, country of citizenship: If you are not a US citizen, what country are you a citizen of?

Are you Hispanic/Latino?

Yes

No

Are you Hispanic/Latino?

If Hispanic/Latino, is your background (select one):

Central American

Mexican

Puerto Rican

Dominican

Other Hispanic/Latino

South American

If Hispanic/Latino, is your background (select one):

All students, please indicate your race background (select one or more):*

American Indian or Alaska Native

Asian

Black or African American

Native Hawai'ian or Other Pacific Islander

White

please indicate your race background

***If you have questions about the use of this information, please contact the Office of Workforce Education at 607-936-5501***

The Personal Privacy Protection Law requires this notice to be provided when collecting personal information from individuals. The authority to request this information is found in section 355 (2) (i) of the Education Law.

Cancellation and Refund Policies:

Cancellations will be determined 3 days prior to start date. Should SUNY Corning Community College’s office of Workforce Education and Academic Pathways cancel a course, refunds are automatically generated. Students may cancel and request a full tuition refund anytime up to 48 hours prior to the start of class. Last minute cancellations by a student or failure to attend will NOT qualify for a refund. Students should make a cancellation request in writing, by email to ilearn@corning-cc.edu, or by phone to 607-936-5501, and should request confirmation of their cancellation. In cases of inclement weather or other emergency conditions, call 607-962-9222 for college closure information.