A copy of this form will be sent to the Registrar's Office. All requests take 3-5 business days to process. Fields marked with a * are required fields General Information * Registration Term: SelectSpring 2021Summer 2021Fall 2021Spring 2022Summer 2022Fall 2022Spring 2023Summer 2023Fall 2023Spring 2024Summer 2024Fall 2024 University ID: (if applicable) SSN: (optional) UR Affiliation(s): Faculty/Staff Student: Undergraduate Graduate Visiting Student: Undergraduate Graduate Alumni Other: * First Name: Middle Name: * Last Name: Suffix: (Jr,III, etc.) Previous Name(s): * Street Address: * City: * State/Province/Territory(type N/A if none): * Postal Code: * Country: * Birthdate: (Month) SelectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember * (Day) Select12345678910111213141516171819202122232425262728293031 * (Year) Select19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 * Sex: Select Female Male Undisclosed You are under the age of 18, a parent must sign this form. * Telephone: * Email: In case of emergency, contact: * Name: * Phone: * Relationship: Degree and Criminal History Status Yes No *Are you currently enrolled in a degree or certificate program at UR?If no, are you interested in pursuing a certificate or degree? *Have you applied to, or, are you applying to a University of Rochester degree program? *Have you previously attended the University of Rochester? *Are you eligible for the University of Rochester tuition benefits? Please contact the Office of Total Rewards for eligibility questions.Please visit the Office of Continuing Studies site for the Tuition Waiver Enrollment Process. *Do you hold any post-secondary degree(s)?List all degree earned: *Have you ever been subjected to disciplinary action by any school, college, university or branch of military, or convicted of violating any state or federal law, excluding minor traffic violations?If yes, explain: Citizenship Information IF YOU ARE NOT A U.S. CITIZEN: Country of Citizenship: Type of Visa: Visa Expiration Date: Home Country Permanent Address: Are you a permanent resident of the United States? Select Yes No IF YOU ARE A U.S. CITIZEN: Current State of legal residence: SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConneticutDelawareFloridaGeorgiaIdahoHawaiiIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming If New York State, what county? (e.g., Monroe) State when you first attended UR: SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConneticutDelawareFloridaGeorgiaIdahoHawaiiIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming If New York State, what county? (e.g., Monroe) U.S. CITIZEN AND NON U.S. CITIZEN: Are you Hispanic/Latino? Select Yes No Prefer not to say Regardless of your answer to the previous question, select one or more races you identify with: American Indian or Alaska Native Black or African American White Asian Native Hawaiian or Other Pacific Islander Course Information (Please utilize example below to fill out your course selections) Course Audit?(Y or N) Course Title AAAS 106-1 N The Making of Modern Africa Select Y N Select Y N Select Y N Select Y N Select Y N Select Y N Tuition and Fees Information For course rates during regular academic terms, please visit the Continuing Studies Site For course rates during the summer term, please visit the Summer Site Financial Certification I certify that I am financially responsible to the University of Rochester for any and all charges incurred. I further certify and understand that, should my student account not be kept current, the University has the right to assess collection costs, late payment fees, and place a hold on my account that prevents further registration and printing of transcripts. * Student Signature: * Date: Students under the age of 18 must have their parent/guardian sign the following: I, , the parent/guardian of agree to be responsible for payment pursuant to the terms of this payment agreement. *Parent Signature: *Date:
