SEATTLE CENTRAL ENROLLMENT APPLICATION FOR TRAVEL/STUDY STUDENTS S ECTION 1 ( TO B E C OMPLETED B Y A LL S TUDENTS) Social Security Number I authorize this college to use my Social Security Number to obtain employment and wage information held by the Employment Security Department for purposes of state and federal educational reporting, o Yes, I give my consent. evaluation and research. o No, I do not consent to the use of my SSN for the above stated purpose. Student I.D. Number This number will be assigned to you for future transactions. You will use this number to access grades, view your schedule, to register, to pay tuition, and for other administrative services. Are you a new student? o
YES o NO 20 o
o
NORTH SEATTLE CENTRAL SEATTLE o
o
NORTH o
SUMMER o
FALL Street Address o
o
SPRING WINTER SOUTH SEATTLE SVI Sex o
o
New address since last registration? o
YES o
NO Last Name, First Name M.I. Phone No. FEMALE MALE Apt No. Program of Study City State City and State o
o
o
Zip o
o
Please mark one or more boxes to indicate what race you consider yourself to be: o INDONESIAN o
AFRICAN o
ARAB o JAPANESE o
CHINESE o KOREAN o
FILIPINO o THAI MEXICAN OTHER What is your sexual orientation? o
Bisexual o
Gay o
Lesbian Zip If you are not a citizen, what is you immigration status? o
Student Visa o
Visitor Visa o
o
E-­‐Mail Address Mailing Address (if different from street address) Are you a Citizen? o
YES o
NO Are you a Spanish/Hispanic/Latino Ethnicity o
YES o
NO o
PUERTO RICAN o
CUBAN Birth Date (M/D/YR) Permanent Resident Refugee o
o
o
o
Other _________________ o
VIETNAMESE WHITE OTHER ASIAN/Pacific Islander OTHER_________________________ The college appreciates your response to the following questions. All information will be maintained with the strictest confidentiality. What is your gender identity? Queer o
Gender Neutral o
Feminine o
Prefer not to answer Straight/Heterosexual o
Transgender o
Masculine o
Androgynous Other o
Other Do you have a physical or mental impairment that substantially limits one or more life activities such as: Hearing-­‐Seeing-­‐Speaking-­‐Walking-­‐Breathing-­‐Learning or Caring for yourself? YES o
OR Prefer not to answer NO I hereby certify that to the best of my knowledge, all statements on this form are true and correct. Student Signature or Designee Date SECTION 2 ( TO B E C OMPLETED B Y A LL S TUDENTS) Item # Course o Section Credits Signature of Instructor Expiration Date Item # Course o Section Credits Signature of Instructor Expiration Date Item # Course o Section Credits Signature of Instructor Expiration Date OFFICE USE ONLY Resident Fee Paying Intent Program Type Biographic Sectioning SEATTLE CENTRAL ENROLLMENT APPLICATION FOR TRAVEL/STUDY STUDENTS SECTION 3 (TO BE COMPLETED BY ALL STUDENTS) Are you a veteran? o
o
How long have you lived continuously in WA State? Years Months ______________________ ________________________ Yes No Were you financially independent from your parent or legal guardian for the previous calendar year? o
Yes o
No EDUCATIONAL BACKGROUND (Last High School Attended) If no, how long has your parent been a resident in WA State? Years Months _______________________ _________________________ City State Year City State Year Last College Attended What is your main long term goal for attending Seattle Central Community College? o
11 Taking Courses Related to Current or Future Work o
12 Transfer to a 4-­‐year College How long do you plan to attend this college? (Select one) What is your work status while attending college? (Select one) What is your prior level of education at entry to Seattle Central? (Select one) What was your family status when you started at Seattle Central? Were you….. (Select one) Please provide the name of the organization that arranged your activity o
o
13 High School or GED 14 Explore Career Direction o
o
Yes No Yes No 15 Personal Enrichment 90 Other _________________________________ o
o
o
11 One Quarter 12 Two Quarters 13 One Year o
o
o
14 Up to Two Years, No Degree Planned 15 Long Enough to Complete a Degree 16 Don’t Know o
o
11 Full-­‐Time Homemaker 12 Full-­‐Time Employment (Including self-­‐employment and military) o
o
o
o
o
o
11 Less Than High School Graduate 12 GED 13 High School Graduate o
o
o
o
o
o
11 A Single Parent with Children or Other Dependents in your care 12 A Couple with Children or Other Dependents in Your Case 13 Without Children or Other Dependents in Your Case What type of activity are you participating in? o
Language Program o
Cultural Program Graduate? o
o
Graduate? o
o
o
90 Other (Indicate) 13 Part-­‐Time-­‐Off-­‐Campus 14 Part-­‐Time-­‐On-­‐Campus 15 Not Employed but Seeking Employment o
o
16 Not Employed, Not Seeking Employment 90 Other (Indicate) 14 Some Post H igh School but Not Degree or Certificate 15 Certificate (Less T han Two Years) 16 Associates Degree o
o
17 Bachelor’s Degree or Above 90 Other (Indicate) o
90 Other (indicate) In what county is your travel/study activity? o
o
Internship Volunteer Activity “YOUR SOCIAL SECURITY NUMBER IS CONFIDENTIAL AND UNDER FEDERAL LAW CALLED THE FAMILY EDUCATIONAL RIGHT & PRIVACY ACT, THE COLLEGE WILL PROTECT IT FROM UNAUTHORIZED USE AND/OR DISCLOSURE IN COMPLIANCE WITH STATE/FEDERAL REQUIREMENTS. DISCLOSURE MAY BE AUTHORIZED FOR THE PURPOSE OF STATE AND FEDERAL FINANCIAL AID, HOPE/LIFETIME LEARNING TAX CREDITS, ACADEMIC TRANSCRIPTS, ASSESSMENT OR ACCOUNTABILITY RESEARCH.” (SENATE BILL 5509) The Washington State Community and Technical Colleges does not discriminate on the basis of race, color, creed, religion, natural origin, sex, sexual orientation, age, gender, marital status, disability, or status as a disabled or Vietnam era veteran.