A copy of this form will be sent to the Registrar's Office. All requests take 3-5 business days to process. General Information Fields marked with a * are required fields * Registration Term: SelectSpring 2023Summer 2023Fall 2023Spring 2024Summer 2024Fall 2024Spring 2025Summer 2025Fall 2025Spring 2026Summer 2026Fall 2026 University ID: (if applicable) SSN: (optional) UR Affiliation(s): Faculty/Staff Non-Matriculated Student: Undergraduate Graduate Visiting Student: Undergraduate Graduate Alumni Other: * First Name: Middle Name: * Last Name: Suffix: (Jr,III, etc.) Previous Name(s): Preferred Pro-noun: Select E/ey Eir Em He He/Him Her Hers Him Hir Hirs His Not Listed She She/Her Theirs Them They They/Them Ve Ver Vis Xe Xem Xyr Ze Preferred Name: * Street Address: * City: * State/Province/Territory(type N/A if none): * Postal Code: * Country: * Birthdate: (Month) SelectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember * (Day) Select12345678910111213141516171819202122232425262728293031 * (Year) Select19231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 * 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: Educational Information * Are you currently enrolled in a degree or certificate program at UR? Yes No If no, are you interested in pursuing a certificate or degree? Yes No * Have you applied to, or, are you applying to a University of Rochester degree program? Yes No * Have you previously attended the University of Rochester? Yes No * Do you hold a Bachelor's Degree or higher? Yes No List all degree earned: Citizenship Information IF YOU ARE NOT A U.S. CITIZEN: Country of Citizenship: Type of Visa: 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: SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConneticutDelawareDistrict of ColumbiaFloridaGeorgiaIdahoHawaiiIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew 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 complete the following section using the example listed. Indicate each course you are requesting to take at the University for the semester. If instructor permission is required, please be sure to upload it. Course CourseNumber CourseSection Audit?(Y or N) Course Title Example: 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 Upload 1st Course Permission Document: Upload 2nd Course Permission Document: Upload 3rd Course Permission Document: 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:
