Continuing Education Enrollment Form
( Last Name ) ( First Name ) ( MI )
Houston Community College Student ID Number ________________________________________________________ Gender
Date of Birth / / (mm/dd/yyyy) E-mail Address _____________________________________________________________
Contact Phone: ( ) -
Cell Phone: ( ) -
Street Address City State ZIP Code
This data is required
for state and federal statistical reporting purposes only. There are certain governmental recordkeeping and reporting requirements for the
administration of civil rights laws and regulations. In order to comply with these laws, students are invited to voluntarily self identify their race or ethnicity. The
information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations. When
reported, data will be aggregated and will not identify any specific individual. This information is required but in no way will be used to evaluate your application.
1. Are you Hispanic or Latino?
No, I am not Hispanic or Latino
Yes, I am Hispanic or Latino, Explain:
� Central American � Cuban � Mexican American � Mexican � Chicano � Puerto Rican � South American � Other - Hispanic
2. What is your race? Select one or more:
American Indian/Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
3. Citizenship Status: Are you a US Citizen?
No Country of Citizenship ______________________________________________________________
Military Status: __________________________
Are you a disabled veteran?
No Do you receive VA benefits?
Military Affiliations (Select one or more)
Current/ former member of the U.S. Armed Forces
Current/ former member of the National Guard
Current/ former member of the Reserves
Dependent of a veteran
Dependent of a deceased veteran
Dependent of a veteran with a combat- related injury
Have you lived in the State of Texas for the last 12 months? Yes No If “No” what was your previous state of residence? _________________________
In what School District do you currently reside?
3. In what county do you currently reside?
Course Title Rubric Class # Days/Time
Start Date Location
The information I have provided is complete and correct to the best of my knowledge. If my application is accepted, I agree to abide by the policies, rules and regulations at any school to which
I am admitted. I authorize the College to verify the information I have provided. I further understand that the information submitted herein will be relied upon by the officials of the College in
determining my admission and residency status for tuition purposes and that the submission of false information is grounds for rejection of my application, withdrawal of acceptance,
cancellation of enrollment, and/or disciplinary action.
Applicant Signature _______________________________________________________________________________________________ Date __________________________________________
Houston Community College considers name, address, telephone, date of birth, degrees earned and dates, major field of study, dates of attendance, enrollment status, student classification and name of most
recent previous institution attended, number of hours complete and in progress, directory information. This is done in compliance with the Texas Open Records Law.
If you do not want this information released, please check this box.
With few exceptions, state law gives you the right to request, receive, review and correct information about yourself collected on this form. Rev. 10-29-13
Section A – Personal Data
Intro to Accounting
ACNT 1003 10825 T,TH 6:30pm