IRVINE VALLEY COLLEGE susencio# _ Statoil cose type opin clearly oed caplet ol inormatin with BLACK INK ONLY. Use th frm oo workihet fr apn nine, of submit tthe Ofc of Aso ond Records. |. First Name Middle Name - Last Name _ — Ja, Other names you have used. f none, check box: [”] Teg ace 108 Tam 2._ Social Security # 3,_Date of Birth Meuth Preferred Email 5. Primary Phone Secondary Phone # S . Gender tole Fo] fence | ‘Complete this question amy you are under 19 an ave never been ave. Name of Parent or Legal Guardian Relationship to your [1 Father CJ Mother C1] Legal Guan Cotter {sts persona: 1 Us chien 1 Peart ReenAen OF other onan esience of his perso. Saar Residence covering the posto yors Sew Ora 20 Ol spans 20 Ol summer = 20 Major Code (se lis} 12, What is your main educational goal? Enter the appropriate number (I-16) ia box. Prepare for anew career (aque ne jb hls) ‘Agra in currant obfearer (pda job sl). Discoverldevelop career inceress educational plans and gal (bain a ewonyear Associate’ degre (vocational) itn mst buna eworyearAsocite’s degre (nonvocatina) thant asi Oban vocational carat witot torso (Oban a vocaona cerifeate an eransfe. (Obtain a Bachelors degree after completing an Assocs degree, = Obeain a Bachelor's degree witout compleing an Associates degree Maina icense (eg rursing, el ett). = lmprve base sil in Enlh, reading oF mathemati Complete credits fr high school diploma or GED, Personal developmen (rtelleca clue, Undecided onan edition goa Move rom noncredit coursework to cree coursmork. Founyear college suden aking course 1 meet fouryear calloge requirement 13, Enrolment Status. Enter the appropriate mumber (I-5) in box 1 = Firsime in collge (aot ia igh schoo at che sme ta}, 11 Freie at vine Vay or Sdleback have attanded another college 21 Resuing stdene to Irvine Villey or Sddebac afer sen fora erm, 5 Earolng in high schoo (or lower grades) and colog the same ime. 8, Legal AddressIResidence (do Nat use P.O. box or business address): 4a, Mailing Address Gf fforent from legal address) Jn. What is your racelethnicity? Circle one or more numbers: ‘American InaniAtslan Nave 13 = Fling ‘Asan Camodan 14 = Hispanic Over ‘Asia: Chinese 15 = Heviean, Mexican Ameen, ‘Asian Indan Chino ‘Asia: panese 16 = Pacfe lander: Guamian ‘Asia: Korean 17 = Pace elander Haaian ‘Asia: Lacan 1 = Pace lander: Other ‘Asian Other 19 = Pace blander: Samoan ‘Asian: Vietnamese 20 = South American Blac or Afiean American 21 = White Cena American ar war Re | Re ae 9. Ethnicp? AreyouHinpancortacio? TH, Highest Edveaonal Seaton = Tye (no Enter the appropriate number (1-9) | | and year in boxes. {= Exped aUS.Migh School ciplora in 2. © Special sedene currenly enrolled in grade 12 or below. [Dam curently a senior in high echoel and wil gradete on 1D Lam curently enroll in grades KI = Nota high school graduate curently enol in aut schoo Nota high school waduate li attended high school in = Passed the GED or rceveda carfieate of HS. equilency in. tamed Caldoria High School Pofiency Ceofaten_ Eamed a Foreign Secondary diploma or cerefesteofgreduntion in = Famed an associate degree in Recaived a bachelor’s or higher degree in SOUTH ORNGE COUNTY COMMUNITY CoULEE OSTRCT APPLICATION FOR ADMISSION ‘Continue on other side15. Fullname of he st high schol you stoned Ue Lasteotege attended. ttnne checkbox: [_] Ciy ‘SeaxeFaregn Coumiry ‘Gane Larned CaianiCoumry ~ ‘Degree Awarded High Seo! Graduation Dae: Moth — Oe ter TT itary Saen Chek he appropriate bo ~ 1G None apy tome 1 Cl Menber dred wt ye itary Discharge Dae 2 Camenty seve mir. 5 CMe deed oro yr ago etran) lary Home (State) of Records 2 Dependent of red ace my ¢ C1 Caren in Resa oF Naor Gard 18. Cheri status, Place of Births oe _ Check the appropriate box (I~6): ws “ 10 UscHen 40 patee ee 1 Ake ned 2 Pome RansA Nae ec ote 5. Secon in fe Bae ite 30 Terry heen hve a — 6 Cort 19, Mypresent stayin California began: Month ote Yer Have you been 2 resident of California forthe ast two yearst Cl Yes CJ No sc any adn ctesetates you hve resided in during the pst cwo years (oe including your currant legal adress) 20, Are you now or fave you ever besna dependent or ward ofthe state tough Calforias eld welare sys? C] Yer C] No {you are 19 years of age or older answer ths following questions about yourself, you are under 19 years of age newer the following questions about your parents). Within ce ase ewa years, hive you (orf youre under 1, have ether f your parents ev— + eegtred co voto a ste other than Catforst (Yee CI No Myenwhatyert +e leg acon nasa other than Clforsiat Cvs CN ttyeswtatyer + sended 3 non-Calforiacolegeiniversy aa resent of cat sta? ves CI) No tyes. what year? + fled 2 nansteident for Calforn Ste zane Tx purposes? Cee Tne yenwatyar NON-DISCRIMINATION POLICY? All prosrams and aves ofthe Sows Orange Couney Community College Disirict shall be operated ina manner which ree of dsrmination on the basis of race, cor natlonal orig ancestry regon cred gehder mara status, soual orenatin, ge, handp or veeran’ status. ~ NOTICE OF FINANCIAL ASSISTANCE PROGRAMS: la aware thac| may apply for franca ettance in deform of gran, work sud ardor ste ont, for upto the total cost of ny education including enrelinen fee, books and supple, eransportaton and room and board expense am enrolled fulcine or parttime imam elle program of sud (e, certieate asocate degree. or ans) More inferno. including one src, avasble at the Franc Aid Office 949/451-5287 [email protected] + yoo etal DISABILITY NOTICEEIf you have dbl please drop and vac he Supportive Services Ofc at vine lly Collage, Rm SC 130,c0ensore that your aida ade ae met or ell the oes se (949) 451-5243 ® NOTICE TO STUDENTS: ‘Your rponses to quesione mared wih dis arbel wil be wied t pronde you with formation on college programs and serve | Indlor fr research and seiseal purposes on. elie to provide thi Inermation wil not be Ud to dry admision co the college or ary of Ws programs. 1 adaina informacion i needed t determine your residence status, yu wil be requied to cmplate 2 supplemental residence questonnare andlor to present evidence in seccrdance rth Education Code Seecore 68040 a seq The burden Of proof to eenrly demonstrate both pysial presence in California ad intent ro etableh California Featdce ls wth the student 21. Certification: declare under peat of perry thal sformaion on thier is erect. understand tht afeton or wiBldng of ntormason required on tis frm shail corsiute pounds for dems Date — Signature