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
Non Credit 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 complete the entire form. This form is for Non Credit (500&600 courses) and
in-service (9000) courses only unless approved by the Registrar.
1. Registration Information
Term Registering For: Last Term Attended:
2. Personal Information
Last: First: Middle:
Preferred Name: Previous Names:
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. Name of Last High School Attended & Graduation Date
High School: State: Graduation Date:
11. 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)
The following information must be answered each term for reporting purposes
12. Educational Objective for Term
Discover career interest/goal Educational development Maintain certificate/license
Prep for new career/job skills Improve basic skills Undecided on goal
Advance in career/update job skills Uncollected/Unreported
13. Are you on any of the following economic assistance programs?
TANF/AFDC/CalWORKs SSI
General Assistance None
14. Are you a single parent with custody of a minor child? Yes No
15. Are you a displaced homemaker? Yes No
16. Are you a migrant worker or child of a migrant worker? Yes No
17. 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
18. 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). (If Yes answer Status below)
Yes No
Current in-state Previous in-state Previous temporary status
Current out-of-state system Previous out-of-state
19. Are you considered homeless (lacks a fixed, regular and adequate nighttime residence) Yes No
20. Were you subject to any stage of the criminal justice process? Yes No
21. Have you been unemployed for 27 weeks or longer? Yes No
22. 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
Please list the courses you wish to
attend, with CRN (Course Registration
Number) and Course Title
CRN
Course Title
I verify that I am responsible for the course choices listed above and that I have read any advisories in the COS Catalog. The
information on this application is true and correct to the best of my knowledge. Falsification of any information may result in my
dismissal from classes. I acknowledge I am responsible for payment of all fees related to the course(s) above.
Student Signature Date
Office Use Only
Signature Date
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