La Manosa

Student Records Information Form
College Use Date

Please type or print in ink all information requested.

Completed by: Campus of Record:

E

W

OSC

WP

What information would you like to update? (Check all that apply) Update your address using your online atlas account q CHANGE OF PROGRAM q CHANGE OF NAME PLEASE TYPE OR PRINT YOUR NAME AS IT CURRENTLY APPEARS ON YOUR VALENCIARECORDS:
LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME

q CLASSIFY AS A DIRECT CONNECT PARTICIPANT
VALENCIA ID / SSN

DATE OF BIRTH

/
Month Day

/
Year

Change of Program
1. List all colleges attended:

Change of Program requests received after the Drop/Refund Deadline for a term will be processed for the following term. To change to a degreeseeking student all officialtranscripts (high school and/or college) must have been received by Valencia. To be considered degree-seeking at Valencia, students must have a standard high school diploma, completed a GED, or have transfer work from a regionally accredited institution.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Degree-seeking students must complete & satisfy Assessment requirements. (For information on Assessment, go to www.valenciacc.edu/assessments) 3. Indicate your primary (1) and/or secondary (2) choice of Program or Technical Certificate. (Seereverse side of this sheet for list of programs.) Primary _______________________________________________________ Secondary_____________________________________________Catalog Term* __________________________ *If you indicate a Catalog Term and you are pursuing two programs, the Catalog Term will be updated for both programs. Catalog Terms are in effect for five years; however, if you change yourprogram you will be required to follow the Catalog Term currently in effect at the time you submit your Change of Program request. 4. If you no longer plan to pursue a specific program, degree or certificate, please check the selection below that best describes your situation: q Job improvement q Do not intend to earn a Valencia Degree (Personal Interest) q Teacher Recertification q TransientStudent (You will be transferring credits to your home institution where you will be obtaining your degree)

5. Have you been awarded Financial Aid (loans, grants, scholarships) for the current term? ___Yes ___No 6. Have you applied for graduation from Valencia? ___Yes ___No If yes, for which term? ___________________________

Direct Connect Classification
1. After you complete your degree atValencia, are you planning to complete a Bachelor’s Degree with the University of Central Florida? ___Yes ___No If no, where? ________________________________________________________________________________________________________________________________________________________________ 2. If you indicate a Florida institution above, do you agree to allow Valencia to release your academic record tothat institution? ___Yes ___No What is your expected date of graduation from Valencia? ___________________________________________________________________________________________________________

Change of Personal Information

Change of Personal Information must be accompanied with appropriate official documentation.

q I am a Valencia employee* *Valencia employees must contact HumanResources to complete these updates.

q Court Document q Social Security Card

q Driver’s License q Marriage License q Other legal document

INFORMATION TO BE CHANGED (NEW NAME AS IT CURRENTLY APPEARS ON YOUR SOCIAL SECURITY CARD):
LAST NAME FIRST NAME MAIDEN NAME VALENCIA ID / SSN

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

BIRTHDATE

OTHER

STUDENT SIGNATURE...