Participant Information Form

Course*Please include the full name of the course.

Date Course Begins*

Name (First, MI, Last)*

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

Street Address*

City*

State*

Zip Code*

Phone number(s)*Home and/or Cell

Email*

Work Numberarea code/number

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

Date of Birth*

Gender*

Female

Male

Prefer not to answer

Are you a US citizen*

Yes

No

If no, country of citizenship:

Are you Hispanic/Latino*

Yes

No

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

Central American

Mexican

Puerto Rican

Dominican

Other Hispanic/Latino

South American

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

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific

White

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 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 call to 607.936.5501 and should also request confirmation of their cancellation. In cases of inclement weather or other emergency conditions, please call 607.962.9222 for college closure information.