EMPLOYMENT STATUS: Improve Job Skills Work 35 or More Hours Work less than 35 hours per week Not Employed Retired Course Reference Number SOCIAL SECURITY NUMBER: LAST FIRST 9 • oregon coast community college • fall 2013 (PROVIDING YOUR SOCIAL SECURITY NUMBER IS VOLUNTARY) GENDER: F M Y N U.S. CITIZEN: OREGON RESIDENT Y N ARE YOU A VETERAN OF THE MILITARY: Date: ________ Term that you plan to enroll in: ____________________________________________________________ CITY STATE ZIP EMAIL ADDRESS:___________________________________________ BIRTHDATE:_______________________________________________ MONTH DAY YR TELEPHONE:_______________________________________________ ADDRESS_______________________________________________ NAME:__________________________________ WHAT IS YOUR MAIN REASON FOR ATTENDING OREGON COAST COMMUNITY COLLEGE? OREGON COAST COMMUNITY COLLEGE REGISTRATION/ADMISSION FORM [community ed. & small business classes. to register for credit classes, visit oregoncoastcc.org.] Use of Social Security Numbers: The following is Oregon Coast Community College’s official disclosure statement regarding use of social security numbers: Official Disclosure Statement: AR 581-41-460 authorizes Oregon Coast Community College to ask students to provide their social security numbers. The number will be used by the College for reporting, research, and record keeping. Numbers will also be provided by the College to the Oregon Community College Unified Reporting System (OCCURS), which is a group made up of all community colleges in Oregon, the State Department of Community Colleges and Workforce Development, and the Oregon Community College Association. OCCURS gathers information about students and programs to meet state and federal reporting requirements. It also helps colleges plan, research, and develop programs. This information helps the colleges to support the progress of students and their success in the workplace and other education programs. OCCURS, or the College may provide social security numbers to the following agencies or match it with the records from the following systems: • State and private universities, colleges, and vocational schools, to find out how many community college students go on with their education and find out whether community college courses are a good basis for further education; • The Oregon Employment Department, for analysis which helps state and local agencies plan education and training services to help Oregon citizens get the best jobs available; • The Oregon Department of Education, to provide reports to the state and federal governments. The information is used to learn about education, training, and job market trends for planning, research, and program improvement. • The Workers Compensation Division, to track the successful training of injured workers. • The Oregon Department of Revenue and collection agencies only for purposes of processing debts and only if credit is extended to the student by the College. • The National Student Loan Clearinghouse for student financial aid processing and/or research on transfer. • The American College Testing Service, if students take the ASSET placement test, for research purposes. • The Internal Revenue Service, to provide required information related to the Taxpayer Relief Act of 1997. Oregon Coast may also release social security numbers to firms or agencies under contract with the College to provide instruction or research services. Social security numbers will be used only for the purposes listed above. State and federal laws protect the privacy of student records. I certify that all statements on this application that are completed are true. I also understand that if I am admitted and do not enroll for the term to which I admitted, I will need to reapply for admission. No submitted materials will be returned and/or duplicated. SIGNATURE:_____________________________________________ DATE:___________________ Personal Enrichment MI ____________________________________________________________________________________ Class Title Y Start Date/ End Date N Fall ___ Winter ___ Spring ___ Summer___ Day Mother: Middle School/Jr High (1) High School (2) College or beyond (3) NAME OF SCHOOL____________________________ STATE:_______________________________________ OCCC WOULD APPRECIATE RESPONSE TO THE FOLLOWING: HIGH SCHOOL: DID NOT COMPLETE HIGH SCHOOL GED STILL IN HIGH SCHOOL HIGH SCHOOL GRADUATE Highest education your parents completed: Father: Middle School/Jr High (1) High School (2) College or beyond (3) WHITE AFRICAN AMERICAN HISPANIC AMERICAN INDIAN ASIAN/PACIFIC ISLANDER HAVE YOU EVER ATTENDED ANOTHER COLLEGE OR Y N UNIVERSITY? NAME OF COLLEGE________________________________ STATE:____________________________________________ Oregon Coast Community College releases only very limited information regarding students: dates of enrollment, degree or certificate, or honors awarded. If you do not want any person outside the college, including prospective employers, to know any of these, you must file a “Request for Non-Disclosure of Student Information” form with the Registrar. Time Location