Rutgers: University College Community – Request to Affiliate with UCC

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Please complete this form in its entirety. Should you encounter an error please e-mail: ucc@rci.rutgers.edu.

If you'd rather download the form, fill it out manually and fax (732-932-7906) or mail it back to us, then click here.

Demographic Information

An undergraduate student enrolled in one of the schools at Rutgers-New Brunswick/Piscataway is eligible to affiliate with, and utilize the programs and services offered by, the University College Community if he or she meets one or more of the following criteria. Please check all that apply:

	has been out of high school for 4 or more years at the time of application to Rutgers-NB or at time of first registration.
	is part-time taking fewer than 12 credits for 2 semesters or more.
	has had an interruption (typically 2 years or more) of formal undergraduate education either at Rutgers or before attending Rutgers.
	is not enrolled in a degree program (nonmatriculated).
	is pursuing post-baccalaureate studies primarily in undergraduate courses.
	is pursuing off-campus degree completion program through a Rutgers-NB School.
	has significant non-academic commitments as indicated:

Non-academic Commitments Information

If you wish to affiliate with UCC due to having significant non-academic commitments, for example, documented issues pertaining to work, family, mental or physical health, or finances that would preclude or severely impede a student from obtaining a degree through traditional academic full-time study. Please answer the following:

	Work hours per week
	Company address, phone and contact person:
	Parent/Guardian of children
	List name(s) and age(s):
	Guardian of elderly parents
	List name(s) and age(s):
	Head of Household
	Financially independent student as documented at the Rutgers Financial Aid office
	Suffer disabilities as confidentially documented at Rutgers’ Disabilities Office

Military Association

	Active duty military (name branch):
	Veteran (inactive military: name branch)
	Veteran Dependent
	Spouse of a Veteran
	Surviving Spouse of Deceased veteran
	Surviving Child of Deceased veteran
	or other:

Check semester and year of admission to Rutgers:

Fall

Spring

Name:

Address:

Phone Number(s):

E-mail Address:

RUID:

Academic Information

School of Enrollment at Rutgers:

Major/Intended Area of Study:

Minor (if applicable):

Reason for joining the UCC:

I declare that all information provided is true, accurate and complete. This form must be signed with your e-mail address if you're filling it out online.

Signature:

Date:

All information provided on this form and supporting documents will be kept confidential.