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 email@example.com. 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 Home Business
Gender oMale oFemale
Is English your primary language?
If not, please indicate your primary language
Are you of Hispanic or Latino orgin?
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?
High School Information
Where did you last attend high school?
High School Name
City _____________________________________________________ State ________
oForeign high school graduate oHome schooled oNone
oGraduated oWithdrawn from High School oHigh School Equivalency oOther Equivalency oCurrently Attending High School
______ / _______ / _______ 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
Admissions Aid Oce: Building S, Room S101