____________
_______
STUDENT STATUS
(Select one)
NEW
CURRENTLY ENROLLED
FORMER
(When? ________ )
LEGAL LAST NAME
SOCIAL SECURITY NUMBER (SSN)
CLASS REGISTRATION FORM (Complete all boxes)
QUARTER:
SUM FALL WIN SPR YEAR
To comply with federal laws, we are required to ask for your Social Security Number (SSN) or Individual
Taxpayer Identification Number (ITIN). We will use your SSN/ITIN to report payments made by you
that may qualify for a tax credit or a tax deduction on your income tax return. We may also use this
information to administer state/federal financial aid, to verify enrollment, degree and academic
transcript records, and to conduct institutional research. If you do not submit your SSN/ITIN, you will
not be denied access to the college; however, you may be subject to an IRS penalty of $50. Pursuant to
state and federal law, the college will protect your SSN from unauthorized use and/or disclosure.
STUDENT IDENTIFICATION NUMBER (SID)
Your SID is assigned to you.
You must use your SID to register for classes, get grades,
pay tuition, and other services.
LEGAL FIRST MIDDLE INITIAL PREVIOUS LAST NAME (if applicable)
ADDRESS - NUMBER & STREET & APT. #, ROUTE & BOX OR P.O.
CITY STATE ZIP
DAY PHONE
EVENING PHONE
BIRTHDATE
MO DAY YR
QUARTER CODE: ________
DO NOT WRITE IN SHADED AREA
INTENT PROGRAM PURP ADVISOR CODE
Have you been a legal resident* of WA and lived continuously
in WA for the past 12 months?
YES NO
*A student cannot qualify as a legal resident of Washington for tuition calculation
purposes if s/he possesses a valid out of state driver’s license, vehicle registration, or
other documents that give evidence of being a legal resident in another state.
If NO, how long have you lived continuously in the state of WA?
Were you claimed for federal income tax purposes by parent
or legal guardian in the current or past calendar year?
If YES, has parent or legal guardian lived continuously
in WA for the past 12 months?
Are you active duty military stationed in WA or
spouse/dependent of the same?
Are you WA National Guard or spouse/dependent of
the same living in WA?
EDUCATIONAL BACKGROUND
YES NO
YES NO
YES NO
YES NO
Last High School Attended City State Year Graduated
YES NO
Last College Attended City State Year Graduated
YES NO
STUDENT’S PURPOSE:
What is your main long term goal for attending Pierce College?
Circle the number that BEST applies to your reason for enrolling:
11 Take courses related to current or future work
12 Transfer to a four-year college
13 High school diploma or GED
14 Explore career direction
15 Personal enrichment
90 Other
BE SURE TO COMPLETE IMPORTANT
INFORMATION ON REVERSE SIDE OF THIS PAGE.
I understand that I am fully responsible for paying my tuition and other
debts owed to Pierce College by the tuition due date. Failure to make
payments to Pierce College by the due date may result in my account being
referred to an outside collection agency. I am responsible for all costs
including collection cost of 24% to 35%, 12% interest and reasonable legal
fees as per Washington State Law.
U.S. CITIZEN? YES NO If No, what is your status?
RESIDENT ALIEN/IMMIGRANT REFUGEE
STUDENT VISA VISITOR OTHER _______________
DISABILITY STATUS
Optional (Confidential information used for statistical reporting only)
Do you have a physical or mental impairment which substantially limits one or more major life
activities, such as: seeing, hearing, speaking, walking, learning or working? YES NO
Persons with disability may be eligible for support services and should contact Access and
Disability Services.
A
if
Audit
ITEM NO. COURSE DEPT. & NUMBER CRE DAYS TIME OFFICE USE
9999 Circle Item # if you want to donate $1 to Pierce College Foundation to provide student scholarships.
TOTAL
*
If you do NOT wish to receive credit, put an A in the audit column.
TOTAL
CREDITS
STUDENT
/ /
SIGNATURE X
I accept full financial responsibility as a result of my registration.
DATE
ADVISOR’S
/ /
SIGNATURE X
REFUND POLICY
PLEASE SEE THE ONLINE QUARTERLY
CLASS SCHEDULE FOR COMPLETE
REFUND INFORMATION.
DATE
1507 AF
ADDITIONAL STUDENT INFORMATION
FEMALE
MALE
Please mark one or more boxes to indicate what race you consider
yourself to be:
White (800)
African American (872)
American Indian (597)
Alaska Native (015)
Native Hawaiian (653)
Other Pacific Islander (681)
Vietnamese (619)
Filipino (608)
Chinese (605)
Korean (612)
Japanese (611)
Other Asian (621)
Other Race (specify) ___________________
Are you of Spanish/Hispanic/Latino ethnicity?
No (999)
Yes, Mexican, Mexican American, Chicano (722)
Yes, Puerto Rican (727)
Yes, Cuban (709)
Yes, Other ________________________
Have either of your parents earned a bachelor’s (4 year) degree?
No Yes
The college appreciates your response to the following questions
to assist us in designing programs and services, and creating a
welcoming environment.
What is your sexual orientation?
Bisexual
Gay
Lesbian
Queer
Straight/heterosexual
Other
Prefer not to answer
What is your gender identity?
Feminine
Masculine
Androgynous
Gender neutral
Transgender
Other
Prefer not to answer
PLEASE CIRCLE THE NUMBER THAT BEST APPLIES TO YOU
How long do you plan to attend Pierce College?
11 One quarter/term
12 Two quarters/terms
13 One year
14 Up to two years, no degree planned
15 Long enough to complete a degree
16 Don’t know
90 Other
What is your current work status while attending college?
11 Full-time homemaker
12 Full-time employment (including self-employed and military)
13 Part-time off-campus
14 Part-time on-campus
15 Not employed, but seeking employment
16 Not employed, not seeking employment
90 Other
What is your prior level of education at entry to Pierce College?
11 Less than high school graduation
12 GED
13 High school graduate
14 Some post high school, but no degree or certificate
15 Certificate (less than two years)
16 Associate degree
17 Bachelor’s degree or above
90 Other
What was your family status when you started at the community college?
11 A single parent with children or other dependents in your care
12 A couple with children or other dependents in your care
13 Without children or other dependents in your care
90 Other
JBLM STUDENTS ONLY
Of the following choices, how would you identify yourself?
Active duty military, pay grade: ________
Branch: ______________ (J or K)
Family member of active duty (FAM), branch: ______________ (L)
National Guard (NG), Branch: ______________(J)
Reserves (RES), Branch: ______________ (J)
Retired military (RET)
Veteran (VET)
DOD employee (DOD)
Civilian (CIV)
How are you paying for your courses?
Tuition assistance (TA)
VA CH33 post 9/11 (CH33)
My CAA or Heroes@Home2 (CAA)
Vocational rehab (VOC)
Scholarship (SCH)
Financial aid (FIN)
Self pay (SEF)
Other 3rd party (CNT)
Additional information:
CELL PHONE
Yes – I consent to receiving automated text messages for advising and student support
needs from Pierce College.
No – I do not consent to receiving automated text messages.
Maximum of 7 messages/month. Message and data rates may apply. Text HELP for help.
Text STOP to cancel. Privacy terms and conditions are available at:
www.pierce.ctc.edu/about/policies/text-privacy-policy.pdf
EMAIL ADDRESS
This email will be used for initial contact only. All future college emails will be
sent to your Pierce College student email.
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SID_____________________________
VETERAN STATUS
LAST NAME_____________________________
FIRST NAME_____________________________
TERM_____________________________
You may be eligible for additional services.
Please select one category that best applies to you.
0 Not a veteran/No military affiliation
A Montgomery GI Bill‐ Chapter 30 MGIB‐ AD
B Vocational Rehabilitation & Employment Program‐ Chapter 31 VR&E
C Veterans Educational Assistance Program‐ Chapter 32 VEAP
D Post 9/11 Veterans‐ Chapter 33
E Transfer of benefits to eligible Dependent Child‐ Chapter 33 Transfer of Entitlement (TOE)
F
Eligible Dependent Child of 100% disabled or deceased veteran (Chapter 35) or receiving Veteran Depende
Tuition Waiver
G Selected Reserve‐ Chapter 1606 MGBI‐ SR
H Reserve Educational Assistance Program‐ Chapter 1607 REAP
J Active duty (including national guard/reserves) currently using military tuition assistance
K Active duty military student using military benefits or paying resident tuition rates
L Military dependent of active duty using military benefits or paying resident tuition rates
M Transfer of benefits to eligible Spouse‐ Chapter 33 Transfer of Entitlement (TOE)
N
Eligible Spouse of 100% disabled or deceased veteran (Chapter 35) or receiving Veteran Dependent Tuitio
n
Waiver
V Veterans Retraining Assistance Program (VRAP)
X Veteran receiving benefits not listed above
Z Veteran not receiving benefits, including those who decline using their benefits