Fillable Admissions & Records COS - Registration Form 1. (College of the Siskiyous)

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Admissions & Records COS - Registration Form 1. (College of the Siskiyous)

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PLEASE PRINT
Name
Last:
First:
Year:
Admissions & Records
College of the Siskiyous, 800 College Ave., Weed, CA 96094
Phone: (530) 938-5500 - Fax: (530) 938-5367 – Email: registration@siskiyous.edu
COS - Registration Form
DIRECTIONS: Please complete this entire form (incomplete forms cannot be processed).
Check the box to the right of the number if there is no change from last term attended. If more than a year has
elapsed since last registration you must re-apply to the College.
1. Registration Information
Term Registering For: Last Term Attended:
2. Personal Information
Last: First: Middle:
Preferred Name: Previous Name:
Date of Birth: COS Student ID Number:
3. Gender / Gender Designation
Male Female Not-Transgender Transgender Decline to State
4. Current Mailing Address
Address: City: State: Zip:
Phone: Email:
5. Current Physical Address
Check if same as mailing address
Address: City: State: Zip:
6. Citizenship
US Citizen Permanent Resident Temporary Resident Refugee/Asylee
Student Visa Amnesty Other Status
If you did not specify US Citizen, please indicate the following:
Alien Registration Number or Visa Type:
Issue Date Expiration Date
7. Ethnicity
Asian Chinese Asian Indian Japanese Korean
Laotian Cambodian Vietnamese Other Asian Black Non-Hispanic
Filipino Hispanic Mexican, Mexican/American, Chicano Central American
South American Other Hispanic American Indian/Alaskan Native Pacific Islander
Samoan Guamanian Hawaiian Other Pacific Islander
White Non-Hispanic Unknown Decline to State
8. Directory Information (AP 5040)
May the College release information regarding your attendance and residence to outside inquiries?
Yes No
9. Educational Level
Non-High School Graduate Received California High School
Certificate of Proficiency
Currently Attending High School Foreign School Diploma/Certificate
or Below; Grade _____
Attending Adult School Associate Degree
High School Graduate Bachelor Degree or Higher
Received GED or HS Certificate of Equivalency/Completion
Date Education Level was obtained:
10. Student Type
First time- never attended College First time at COS previously attended another college
Continuing from last semester Returning to COS after an absence of one or more years
K-12 Student (You must complete the attached Permit to Register)
11. Name of Last High School Attended & Graduation Date
High School: Graduation Date: _____________ State: _____________
The following information must be answered each term for reporting purposes
12. Educational Objective for Term
Associate & Transfer Improve basic skills Move noncredit to credit coursework
Transfer without Associate Advance in career/update skills Mtg 4-yr college req-4-yr student
Associate Degree Maintain certification/license Undecided on goal
Certificate of Achievement Educational Development Uncollected/Unreported
Discover Career Interest/Goal Credits for HS diploma/GED
13. Residency Questions
Have you continuously lived in California for the past two years? Yes No
If no, specify state/country: Dates:
If no, length of time in California:
What is your Driver’s License #? State:
Do you have a vehicle? Yes No
If yes, in what state is your vehicle registered?
Do you intend California to be your permanent residence? Yes No
Have you done any of the following in the past two years?
Voted in another state or registered to vote in another state? Yes No
If yes, what state?
Attended out-of-state college/university as a resident? Yes No
Did you file California State Income Taxes for the past calendar year? Yes No
Students under 19 years old and unmarried ONLY
Are your parents or guardians California residents and continuously lived in California for the past two years?
Yes No
If yes, when did your parents enter California: / /
Month Day Year
14. Are you on any of the following economic assistance programs?
TANF/AFDC/CalWORKs SSI
General Assistance None
15. Are you a single parent with custody of a minor child? Yes No
16. Are you a displaced homemaker? Yes No
17. Are you a migrant worker or child of a migrant worker? Yes No
18. Are you or parent/guardian an honorably discharged Veteran? Yes No
Student Military Status Parent/Guardian Military Status
Currently serving on active duty Currently serving on active duty
Veteran Veteran
Member of the Active Reserve Member of the Active Reserve
Member of the National Guard Member of the National Guard
19. Are you now or have you ever been in a court-ordered out of home placement such as a foster home,
group home or court placement with a relative (AKA Foster youth)?
Yes No (If Yes answer Status below)
Current in-state Previous in-state Previous temporary status
Current out-of-state system Previous out-of-state
20. Are you considered homeless (lacks a fixed, regular and adequate nighttime residence) Yes No
21. Were you subject to any stage of the criminal justice process? Yes No
22. Have you been unemployed for 27 weeks or longer? Yes No
23. Parent/Guardian Educational Level
Parent/Guardian 1 Parent/Guardian 2
Grade 9 or less Grade 9 or less
Some high school Some high school
High school graduate High school graduate
Some college Some college
Associate’s degree (AA/AS) Associate’s degree (AA/AS)
Bachelor’s degree (BA/BS) Bachelor’s degree (BA/BS)
Graduate or professional degree Graduate or professional degree
Not Applicable Not Applicable
Term:
Please list the courses you wish to attend, with CRN (Course Registration Number) and Course
CRN
Course
Course Title
Term:
Please list the courses you wish to attend, with CRN (Course Registration Number) and Course
CRN
Course
Course Title
K-12 Students - Special Admission Request
Any student who is attending a traditional K-12 school, high school completion program, or Adult School and is under the
age of 23 must complete the information below.
Student’s age and grade level on first day of COS course.
Age: Grade Level:
Current School:
City: State:
I understand that some course topics may not be appropriate for minors. These courses and grades will be recorded on
the student’s permanent college transcript. I understand that I need a FERPA release on file to access information on my
student’s College records. I swear under penalty of perjury that the above information is true and correct.
Check Below
I hereby authorize COS to share academic (grades, status, GPA, unofficial transcripts) and billing information to the
above school.
I hereby authorize COS to share academic (grades, status GPA) and billing information to:
The code word we will use for the release of information is:
I certify that this student will benefit from college level work and I recommend him/her for enrollment in the course(s)
listed above. (Education Code 76001-02) For Summer Session: I certify that I have not recommended for enrollment in
non-exempt courses at College of the Siskiyous more than five percent of the total number of pupils who completed the
above named student’s grade level. (Education Code 48800)
Student Signature: Date:
Parent Signature: Date:
School Official Signature: Date:
School Official Name (please print):
Phone: Email:
Students Age 15 and Under (as of the first day of the COS semester) - need approval from COS Counseling Services.
Counseling Signature: Date:
Approved Disapproved
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Admissions & Records COS - Registration Form 1. (College of the Siskiyous)

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Completed 25 July 2020

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