C
omplete this admission form and send it to Moraine Valley Community College, Admissions Office, 9000 W. College
Pkwy., Palos Hills, IL 60465-2478, or email to admissions@morainevalley.edu. You also may complete this form at the
Office of Multicultural Student Affairs, Building S, Room S216, (708) 974-5475.
You are eligible to enroll at Moraine Valley Community College if you are:
1. A graduate from an accredited high school
2. A recipient of a high school equivalency certicate
3. At least 18 years old and capable of beneting from college-level instruction. High school students must be at least 16 years old
at the time of registration and submit a completed high school authorization form.
4. Planning to enroll in English as a Second Language, high school equivalency or Adult Basic Education classes
Please enter your full legal name (no nicknames).
First Name _______________________________ Middle Initial ____ Last Name ___________________________ Sux _____
Birth Date ______ / ________ / _________________
MONTH DAY YEAR
Home Address _______________________________________________________________ Apt or Unit # _____________
City _______________________________________ State ____________________________ ZIP code _______________
Email Address _____________________________________________________________
Primary Phone Number ______________________________
Secondary Phone Number ___________________________
Alternate Phone Number _____________________________
Cell Home Business
Cell H
ome Business
Cell Home Business
Gender oMale oFemale
Is English your primary language?
oYes oNo
If not, please indicate your primary language
_____________________________________________________________________________
Are you of Hispanic or Latino orgin?
oYes oNo
Please identify your primary racial/ethnic group
oAmerican/Alaska Native oAsian oBlack or African American
oHawaiian/Pacic Islander oHispanic or Latino oWhite oOther ________________________________________________________
Have you ever served in the military?
oYes oNo
High School Information
Where did you last attend high school?
High School Name
_____________________________________________________________________________________________________
City _____________________________________________________ State ________
oForeign high school graduate oHome schooled oNone
Completion Status
oGraduated oWithdrawn from High School oHigh School Equivalency oOther Equivalency oCurrently Attending High School
Graduation
______ / _______ / _______ What is your degree/certicate objective?
MONTH DAY YEAR oTo complete 1+ courses oCerticate oAssociate Degree
What is your current reason for attending?
oTransfer to a Four-Year Institution oJob Skill Improvement oNew Job Skills After MVCC
oBasic Academic Skills/High School Equivalency/ESL oPersonal Interest/Self Development oOther
Do you plan to transfer to a four-year college or university?
oI plan to transfer oNot planning to transfer
Admission Application
Admissions Aid Oce: Building S, Room S101