Online 5-Hour Pre-Licensing Course Registration Request Form

Online Five-Hour Pre-Licensing Course Registration Request Form
Thank you for your interest in the online Five-Hour Pre-Licensing Course, held remotely through Zoom. Submitting this form authorizes our office to register and bill the individual listed on this form for the Five-Hour Pre-Licensing Course. If additional information is needed for us to register you for a course, or if a class you’d like to sign up for is no longer accepting registrations, we will contact you as soon as possible. Please note:
- This form can only be used to register the individual whose information is listed below. This form must be submitted by the individual listed below, or by their parent/guardian, significant other, or sponsoring employer. Please submit your request and fill out the form again for any additional students you'd like to register.
- Please note that 24-hour notice is required for any cancellations in order to recieve a refund. Failure to give 24 hours’ notice will result in loss of payment; those who did not pay in advance will still be liable for the course fee.
- Students must have their NYS Learner's Permit with them when they login to the course.
- The fee for this course is $55.
Student Name *

Legal First Name Middle Name Last Name
Birth Date *

Month Day Year
Banner ID
Address (must match address on permit) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email Address *
Home or Cell Phone Number *

Area Code Phone Number
Work Phone (optional)

Area Code Phone Number

Please select the course date for which you would like to register. *

Monday, June 13, from 5 to 10 p.m (CRN: 70001) Monday, July 11, from 5 to 10 p.m. (CRN: 70002) Monday, Aug. 15, from 5 to 10 p.m (CRN: 70003)
Student's learner permit number: *
Student's eye color: *
Please upload a picture of the student's learner permit: *

Browse Files

Cancel of
Remote, Online, Offsite Attestation:

I am the student, or the legal guardian of the student identified above in this form.

I understand that SUNY requires offsite and online students to attest that they understand the vaccine requirement for participation in on-campus courses and activities. I am registered for an offsite, online or remote course and, as such, am exempt from the on-campus vaccine requirement and I attest that I will not have an on-campus presence in classes or events.

I also understand that if I register for an on-campus course, I must submit proof of COVID-19 vaccination and receive confirmation of the validation of my vaccine information via email, prior to my arrival for an on-campus course.
I have read and understand the attestation above. *

Yes, I have read and understand the above information. By clicking Yes here, I am confirming my attestation.

IMPORTANT - Please read the following, then click the "Submit" button below to submit your registration request. Contact the Office of Continuing Education at 518.743.2238 or conted@sunyacc.edu with any questions.
- The information submitted in this form will be used by Continuing Education staff to register the individual listed on this form for the Five-Hour Pre-Licensing Course.
- Once you have been officially signed up for the class in the College’s registration system, Continuing Education staff will send you a confirmation by email or phone, as well as send a hard copy of the confirmation and bill to your mailing address.
- If a course is full and unable to take additional registrations , or if we need to clarify additional details to finalize your registration, we will contact you by phone and/or email as soon as possible.
- Please note that you will be automatically billed via mail for the course once your registration has occurred. 24-hour notice is required for any cancellations in order to recieve a refund. Failure to give 24 hours’ notice will result in loss of payment; those who did not pay in advance will still be liable for the course fee.
By clicking the submission button below, I confirm that I am the individual listed on this form, or their parent/guardian, or their significant other, or a sponsoring employer.
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Online Five-Hour Pre-Licensing Course Registration Request Form