Fillable Application for Admission (Merced College)

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Application for Admission (Merced College)

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Application for Admission
Personal Information
First Name Middle Name Last Name
Previous Name(s) Preferred Name
Email address
Social Security Number □ Decline to State
Age
Gender
□ Female □ Male □ Decline to State
Date of Birth (MM/DD/YYYY)
Are you Hispanic or Latino? (Circle yes/no)
YES NO
□ Mexican, Mexican-American, Chicano
□ Central American
□ South American
□ Other Hispanic type
What is your race/ethnicity? (Choose one or more)
□ American Indian/Alaskan Native
□ Asian Indian
□ Black/African American
□ Cambodian
□ Chinese
□ Filipino
□ Guamanian
□ Hawaiian
Contact Information
______________________________________ ________________________________________
Cell Phone Number (xxx-xxx-xxxx) Home Phone Number (xxx-xxx-xxxx)
□ I authorize text messages to be sent to the cell phone number above and accept responsibility for any charges that result.
Mailing Address (Street Number, Name, and Apartment/Unit/Space #)
City
State
ZIP Code
Residential Address (if different from Mailing Address above)
City
State
ZIP Code
Parent/Guardian Information
Regardless of your age, please indicate the highest level of education attained by the parents and/or guardians who raised you.
Parent/Guardian #1 Parent/Guardian #2
□ Grade 9 or less □ Grade 9 or less
□ Some high school, did not graduate □ Some high school, did not graduate
□ High school graduate (diploma, GED, or equivalent) □ High school graduate (diploma, GED, or equivalent)
□ Some college, no degree □ Some college, no degree
□ Associate degree □ Associate degree
□ Bachelor degree □ Bachelor degree
□ Graduate degree (Master, Ph.D., etc.) □ Graduate degree (Master, Ph.D., etc.)
□ Unknown □ Unknown
□ Yes □ No Have you ever been in court-ordered foster care?
□ Yes □ No Were you ever homeless in the last 24 months?
Spring Summer/Fall
2019
2020
2021
2022
Office use:
NAE
SCREENS
Residency Determination
By California law, resident tuition is based on the residency of your parent(s) or guardian(s) until you are 19 years of age, except in
a few special circumstances. Check the box below that applies to you to determine whether you or your parent/guardian must
answer the questions on this page:
Option A: □ I am 19 years old or older.
(You must answer the following questions as they apply to you. Skip to Question #1 below.)
Option B: □ I am under 19 years old and at least one of the following is true about me:
I am or have been married.
I am legally emancipated.
I do not have a living parent or guardian.
I will be on active duty in the armed services as of the day before the first day of the term I am applying for.
I have been self-supporting for at least one year as of the day before the first day of the term I am applying for.
(You must answer the following questions as they apply to you. Skip to Question #1 below.)
Option C: □ I am under 19 years old and NONE of the above statements are true about me.
(Your parent/guardian must answer the following questions as it applies to them.
Continue to Parent/Guardian Info section below.)
Parent/Guardian Information – REQUIRED ONLY IF YOU MARKED OPTION C ABOVE
First Name
Last Name
Relationship
□ Mother □ Father □ Guardian
Residency Certification
Required if chosen citizenship status has * or write N/A if not applicable.
1. What is THE STUDENT’S citizenship status?
□ U.S. Citizen □ Temporary Resident* □ Student Visa F-1/M-1
□ Permanent Resident* □ Refugee/Asylee* □ Other status*
2. Please answer the following questions.
If you chose Option C above, your
Parent/guardian must answer as it applies to them otherwise it applied to you.
Yes No
□ □ Have you lived in California continuously for the last two years?
If NO, when did your current stay in California begin? ____ / ____ / ______
mm dd yyyy
3. In the last two years, have you ever:
Yes No
□ □ Registered to vote in another state? Year: ______
□ □ Petitioned for a lawsuit or divorce in another state? Year: ______
□
□
Attended an out-of-state educational institution as a resident of that state? Year: ______
□ □ Declared residency in another state for income tax purposes? Year: ______
□ □ Is English the language you speak most often? If not English, I mostly speak: _______________________
Military Information
Yes No
□ □ Have you, your parent/guardian (if you are a dependent), or spouse ever served in the military?
If no, skip to next page.
What is your, your parent/guardian, or spouse’s military status? Date of Discharge (if known):
□ Currently on active duty
□ Veteran __________________________
□ Member of Active Reserve mm/dd/yyyy
□ Member of the National Guard
Office Use Only
Residence Status
*Alien Registration #: ______________________
*Date Issued ______________________
*Expiration Date ______________________
*Visa Type ______________________
*Date Issued ______________________
*Expiration Date ______________________
Education Status and Goal
Special Support Services
Please choose one:
□ First time college student □ First time here, been to another college
□ Returning here after an absence □ Continuing (currently enrolled)
□ Enrolling in high school and college at the same time
Merced College is committed to your
educational success and has many
services to assist your particular
needs.
Each category listed below provides
special services to help you succeed.
Please tell us which services would
benefit you in some way:
□ Financial Aid
□ Child Care
□ Disabled Students Program & Services
□ Transfer services
□ Employment Assistance
□ Basic skills
□ Course tutoring
□ English as a Second Language
□ Extended Oppty. Programs/Services
□ CalWORKs
Are you interested in participating in a sport
while attending college?
□ Yes, on a team
□ Yes, not on a team
□ No
Intended Major Number : (see Major Code List on last page of application)
___ ___ ___ ___ ___.___ ___ ___
Please choose one:
□ Obtain a Bachelor’s Degree after completing an Associate’s Degree (A)
□ Obtain a Bachelor’s Degree without completing an Associate’s Degree (B)
□ Obtain a two-year Associate’s Degree without transfer (C)
□ Obtain a two-year vocational degree without transfer (D)
□ Earn a vocational certificate without transfer (E)
□ Discover/formulate career interests, plans, goals (F)
□ Prepare for a new career (acquire job skills) (G)
□ Advance in current job/career (update job skills) (H)
□ Maintain certificate or license (e.g. nursing, real estate) (I)
□ Educational development/personal enrichment (J)
□ Improve basic skills in English, Reading, or Math (K)
□ Complete credits for high school diploma or GED (L)
□ Currently at another college taking courses to meet requirements there (O)
Education History
□ Did not graduate
□ Not in high school yet
□ Currently a K-12 student*
□ Enrolled in Adult School
□ Received a High School Diploma
□ Passed GED
□ Certificate of Equivalency
□ Certificate of Proficiency
□ Foreign Secondary School Diploma
* Students currently enrolled in a K-12 school
must submit a “Permit for Special K-12
Students”
For each class add requested and apply each
semester they take classes.
High School Name
College/University Name
City
State
City
State
Began and Ended (mm/yyyy – mm/yyyy)
Began and Ended (mm/yyyy – mm/yyyy)
Diploma Received (mm/yyyy)
Date of High school Graduation ____________
Date of GED_________
Date of Certificate of Equivalency/Proficiency
____________
GED/Certificate of Equivalency/Proficiency
was obtained:
______________________/________
City State
□Did not complete degree
□ Associate Degree
□Bachelor, Master, or Doctoral Degree
□ Other type of degree
□ Online College
Certification
Selective Service Policy: If you are a U.S. citizen or male living in the United States whose age is 18-25, you have an
obligation to register in accordance with the Federal Military Selective Service Act (50 U.S.C. App 451 et seq.)
Additional information can be obtained at the U.S. Postal Office or at the web site of the Selective Service whose URL
is www.sss.gov/welcome.html.
Residency Policy: You may be required to supply additional information to determine your residency status. Such
information might be evidence in accordance with Education Code Sections 58040 et seq. The burden of proof to
clearly demonstrate both physical presence in California and intent to establish California residence lies with the
student. Failure to provide requested residency information will result in a determination of non-resident status
which, among other things, will greatly increase your tuition rate.
Nondiscrimination Policy: Pursuant to appropriate California Education Code(s) the district shall not deny any person
registration or enrollment because of the individuals ethnic group identification, religion, marital status, age, sex,
handicap, or any other categories, as defined or required by law.
FERPA policy: Under notification of the Family Education Rights and Privacy Act, you may, at the time you actually
enroll, direct the college to withhold release of directory information to persons not employed by the college.
Directory Information includes your name, address, phone number, dates of attendance, major of study,
award/degrees received, date of birth and the most recent institution previously attended.
Social Security Number: Be informed that you cannot be required to provide a Social Security Number, which is used
by colleges to identify student records, and is authorized by the state Chancellor’s office of California Community
College system for evaluation of educational programs and services. You may refuse to provide it. Also be informed
that Public Law 104-208 known as the Solomon Amendment requires Merced College to provide student directory
information to the Department of Defense, including Military recruiters.
1098-T Information: The 1098-T is a tax form that is sent to students who paid “qualified educational expenses” in the
preceding tax year. Qualified expenses include tuition, any fees that are required for enrollment, and course materials
the student was required to buy from the school.
Financial Aid Acknowledgment: Federal and State financial aid programs are available and may include aid in the form
of grants, work study, and/or available student loans. I am aware that I may apply for assistance for up to the total
cost of my education including enrollment fees, books and supplies, transportation, and room and board expense. I
may apply for financial assistance if I am enrolled in an eligible program of study (certificate, associate degree,
transfer) and may receive aid if qualified, regardless of whether I am enrolled full-time or part-time.
Do you authorize Merced College to release Directory Information (see FERPA Policy above)?
Yes No
Do you want to receive your 1098-T Tuition Statement electronically (see 1098 information above)?
Yes No
Do you acknowledge the Financial Aid policy of California Community Colleges (see Financial Aid policy
above)?
Yes No
Optional Information
Yes No Do you consider yourself economically disadvantaged?
1. Annual income below $12,360 for a single person or $16,590 for a couple, including $4,230 additional per
dependent child
2. Eligible for public assistance (i.e. Food stamps (SNAP), free or reduced lunch for your children)
3. Eligible for student Financial Aid
Check box if you receive:
TANF (CalWORKs)
SSI (Supplemental Security Income)
General Assistance
Yes No Are you a single parent?
Yes No Are you a displaced homemaker (see definition below)?
1. Have not worked for 5 or more years except to provide unpaid services to family members
2. Have been dependent on either the income of another family member or on public assistance
3. Are no longer receiving income from either source or
4. Are currently unemployed or underemployed and having difficulty obtaining or upgrading employment
Yes No Have you moved in the preceding 36 months to obtain or to accompany your parents or spouse to obtain
temporary or seasonal employment in agricultural, dairy, or fishing?
I declare under penalty of perjury that all of the information in this application pertains to me and is true and
correct. I understand that falsification, withholding pertinent data, or failure to report changes in residency
may result in disciplinary action from the Merced Community College District. All materials and information
submitted in this application for purposes of admission become the property of Merced Community College
District.
Student Signature: _______________________________________________ Date: ______________________
ASSOCIATE DEGREE MAJORS AND CERTIFICATE PROGRAMS 2019-2020
05000.AA
Accounting (AA)
09102.CL
Drafting: CAD Draftsman – Mechanical (CL)
10400.AA
Music (AA)
05000.CT
Accounting (CT)
09104.CT
Drafting: CAD Drafting – Architectural Design (CT)
12500.AS
Nursing, Registered (AS)
05007.AA
Administrative Medical Office Professional (AA)
09105.CT
Drafting: CAD Drafting – Mechanical Design (CT)
12550.AA
Nursing, Vocational (AA)
05007.CT
Administrative Medical Office Professional (CT)
09103.CB
Drafting: CAD Operator (CB)
12550.CT
Nursing, Vocational (CT)
05008.AA
Administrative Office Professional (AA)
09040.AA
Electronics: Computer Networking Technology (AA)
13160.AST
Nutrition and Dietetics (AST)
05008.CT
Administrative Office Professional (CT)
09040.CT
Electronics: Computer Networking Technology (CT)
13161.AA
Nutrition and Foods (AA)
01052.CL
Agricultural Chemicals (CL)
09250.AA
Electronics: Electronics Technician (AA)
13161.CL
Nutrition and Foods (CL)
01050.AA
Agriculture (General) (AA)
09250.CT
Electronics: Electronics Technician (CT)
15400.AAT
Philosophy (AAT)
01050.CT
Agriculture (General) (CT)
09510.AA
Electronics: Industrial Electrical Technician (AA)
10500.AA
Photography (AA)
01040.AS
Agriculture (General): Advanced (AS)
09510.CT
Electronics: Industrial Electrical Technician (CT)
10500.CL
Photography (CL)
01000.AS
Agriculture Business (AS)
09650.AA
Electronics: Instrumentation and Process Control Technology (AA)
08500.AA
Physical Education (AA)
01000.AST
Agriculture Business (AST)
09650.CT
Electronics: Instrumentation and Process Control Technology (CT)
19700.AST
Physics (AST)
01000.CT
Agriculture Business (CT)
49810.AAT
Elementary Teacher Education (AAT)
20500.AA
Psychology (AA)
01100.AS
Animal Science (AS)
09300.AS
Engineering (AS)
20500.AAT
Psychology (AAT)
01100.CT
Animal Science (CT)
09350.AS
Engineering Technology (AS)
12700.AS
Radiologic Technology: Diagnostic Rad Tech (AS)
22000.AAT
Anthropology (AAT)
15200.AAT
English (AAT)
12700.CF
Radiologic Technology: Diagnostic Rad Tech (CF)
10110.AA
Art (AA)
22200.AAT
Entrepreneurship: Economics (AAT)
22600.AA
Social and Behavioral Sciences (AA)
09000.AS
Automotive Technology: Automotive Collision Repair (AS)
05700.AA
Entrepreneurship: Small Business Entrepreneurship (AA)
22650.AAT
Sociology (AAT)
09009.CL
Automotive Technology: Automotive Collision Repair (CL)
05700.CT
Entrepreneurship: Small Business Entrepreneurship (CT)
12800.CT
Sonography: Diagnostic Medical Sonography (CT)
09010.CL
Automotive Technology: Automotive Technology Level 1 (CL)
01225.AS
Equine Science and Management (AS)
11600.AAT
Spanish (AAT)
09002.CT
Automotive Technology: Automotive Technology Level 2 (CT)
01225.CT
Equine Science and Management (CT)
10550.AAT
Studio Arts (AAT)
09003.AS
Automotive Technology: Master Auto Technician (AS)
21400.AS
Fire Technology (AS)
10600.AAT
Theatre Arts (AAT)
09008.CT
Automotive Technology: Master Auto Technician (CT)
21400.CT
Fire Technology (CT)
10600.AA
Theatre Arts (AA)
04100.AST
Biology (AST)
13160.AA
Foods and Nutrition (AA)
09800.AA
Welding: Welding Technology (AA)
04130.CB
Biotechnology (CB)
13160.CL
Foods and Nutrition (CL)
09810.CL
Welding: Advanced Welding and Metal Fabrication (CL)
04135.AS
Biotechnology-Industry (AS)
11200.AA
French (AA)
Continuing Education (Noncredit)
04137.AS
Biotechnology Pre Professional (AS)
22250.AAT
Geography (AAT)
05150.AA
Business (General) (AA)
19400.AST
Geology (AST)
49165.NC
Basic Skills
05150.CT
Business (General) (CT)
11400.AA
German (AA)
21078.NC
Court Interpreter
05100.AST
Business Administration (AST)
12300.AA
Health Sciences (AA)
49196.NC
ESL Beginning Skills Program
19100.AST
Chemistry (AST)
22300.AAT
History (AAT)
49198.NC
ESL Intermediate Skills Program
13010.AA
Child Development (AA)
21500.AA
Human Services (AA)
49166.NC
Mathematics College Preparatory Basic Skills
13010.AST
Child Development: Early Childhood Education (AST)
21500.CT
Human Services (CT)
10100.NC
Medical Assistant
13015.CT
Child Development: Early Intervention Assistant Specialization (CT)
49300.AA
Humanities (AA)
49199.NC
Reading and Writing College Preparatory Basic Skills
13020.CT
Child Development: Families in Crisis Specialization (CT)
09401.AA
HVAC: Commercial Refrigeration Technician (AA)
07744.NC
Technical Office Occupations
13025.CT
Child Development: Infant/Toddler Care Specialization (CT)
09401.CT
HVAC: Commercial Refrigeration Technician (CT)
Certificates Not Transcripted
13030.CT
Child Development: School Age Care Specialization (CT)
09400.AA
HVAC: HVAC Technician (AA)
15601.AAT
Communication Studies (AAT)
09400.CT
HVAC: HVAC Technician (CT)
05150.CE
Business Information Worker
07200.AST
Computer Science (AST)
49200.CT
IGETC (Intersegmental Gen. Ed. Transfer Curriculum) (CT)
05200.CO
Customer Service Academy (CO)
07300.AS
Computer Science: Management Information Systems (AS)
09550.AA
Industrial Maintenance Technology (AA)
05250.CO
Emerging Leaders Institute (CO)
21150.AA
Criminal Justice (AA)
09550.CT
Industrial Maintenance Technology (CT)
12100.CE
Emergency Medical Technician (CE)
21150.CT
Criminal Justice (CT)
22700.AA
International Studies (AA) DISCONTINUED: Effective 2018 Summer
09780.CE
Entry Level Welding (CE)
21075.AST
Criminal Justice: Administration of Justice (AST)
12400.AAT
Kinesiology (AAT)
12150.CO
Nursing Assistant (CO)
01150.AA
Crop Science (AA)
01350.AS
Landscape Horticulture (AS)
09785.CE
Pipe Welding Technology
01150.AS
Crop Science (AS)
01350.CT
Landscape Horticulture (CT)
05600.CE
Real Estate Salesperson License (CE)
01150.CT
Crop Science (CT)
49501.AA
Liberal Studies (Teaching Preparation) (AA)
05725.CE
Social Media (CE)
49100.CT
CSU General Education (CSU GE Breadth) (CT)
05450.AA
Management/Supervisory Training (AA)
05800.CE
Virtual Office Professional (CE)
01200.AS
Diesel Equipment Technology (AS)
05450.CT
Management/Supervisory Training (CT)
AAT = Associate in Arts for Transfer
AST = Associate in Science for Transfer
AA = Associate in Arts
AS = Associate in Science
CE = Certificate, 6 to <18 units (Not approved by Chancellor’s Office)
CB = Certificate, 12 to <18 units (Approved by Chancellor’s Office)
CL = Certificate, 18 to <30 units
CT = Certificate, 30 to < 60 units
CF = Certificate, 60 or more units
CO = Other award, under 6 units
01200.CT
Diesel Equipment Technology (CT)
05460.AS
Marketing (AS)
13180.CL
Dietetic Services Supervisor (CL)
05460.CT
Marketing (CT)
09104.AS
Drafting: CAD Drafting – Architectural Design (AS)
17400.AST
Mathematics (AST)
09105.AS
Drafting: CAD Drafting – Mechanical Design (AS)
01450.AS
Mechanized Agriculture: Mech Ag Technology (AS)
09101.AS
Drafting: CAD Draftsman – Architectural (AS)
01450.CT
Mechanized Agriculture: Mech Ag Technology (CT)
09102.AS
Drafting: CAD Draftsman – Mechanical (AS)
01453.CL
Mechanized Agriculture: Compact Power Equipment (CL)
09101.CL
Drafting: CAD Draftsman – Architectural (CL)
10400.AAT
Music (AAT)
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Application for Admission (Merced College)

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Completed 5 September 2020

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