Virginia Tidewater Consortium for Higher Education (VTC)
Student Cross-Registration Form
Old Dominion University
01184811
HOME Institution _______________ Student HOME ID# _ ____________
Haynes
Female
Victoria
L
Name _______________________________ Gender ___ _____
middle
first
last
907 Mineo Lane
Portsmouth
VA
23701
Mailing Address --------,------------------- - -------------­
zip code
state
city
number & street
□
(757)537-0906
Phone (__
) _ _ ______ U.S. Citizen? ✔ Yes
area code
□ No
vhayn001@odu.edu
School Email Address __
_______________
Student level at HOME Institution:
Fr. ✔ Soph.
I wish to register for the following course(s) for the:
Circle One
Jr.
Sr.
Foreign students: VISA type
11
Date of Birth
Grad.
month
□ fall □ s.pring ✔□ summer semester
MTH
ECO
Section
Index/
Code No.
161
year
21
UG
Cr.
Grad
Cr.
Regis.
Status*
Grade
HOME
EQUIV
Course
Precalculus I
201
* R-Registered
Cr.
Hrs.
Course Title
day
I 2001
20___
year
Tidewater Community College
Course
No.
13
Other
At _______________ _ _ _ _ __
Name of HOST Institution
Subj.
I
Macroeconomics
C-Course closed, not enrolled
I
N-Course cancelled
5-6-21
Date filed
This student is eligible to take the course(s) listed above and
has completed all prerequisites for the course(s) listed and is in
good standing. Student will be dropped from class if G.P.A.
falls below the minimum required by the HOME and HOST
institution.
By ____________________
Advisor
By ____________________
Chair (if required)
By ____________________
Registrar, HOME Institution
The student understands and agrees to abide by the
administrative rules and regulations of the HOST institution,
including dates and deadlines, rules and regulations governing
academic honesty, student conduct and student discipline and
Add/Drop/Withdrawal policy, throughout the semester enrolled.
By signing below, you authorize your educational records to be
shared between the HOST and HOME institution.
Signature of Student
The above student has been registered for the above courses
as indicated.
By ____________ _____
Registrar, HOST Institution
(PRINT NAME) Registrar, HOST Institution
Student HOST ID# _____________
(PRINT NAME) Registrar, HOME Institution
White copy to HOME institution
(filled in by HOST Institution Registrar)
Yellow copy to HOST institution
Pink copy to Cashiers office
Goldenrod copy to Student
The Virginia Tidewater Consortium is an affirmative action/equal opportunity agency.
Rev. 1/17