Fillable Form 2020: Application for Admission (Merced College)

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Form 2020: 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
2020
2021
2022
2023
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 2020-2021
05000.AA
Accounting (AA)
09104.CT
Drafting: CAD Drafting – Architectural Design (CT)
13160.AST
Nutrition and Dietetics (AST)
05000.CT
Accounting (CT)
09105.CT
Drafting: CAD Drafting – Mechanical Design (CT)
13161.AA
Nutrition and Foods (AA)
05007.AA
Administrative Medical Office Professional (AA)
09103.CM
Drafting: CAD Operator (CM)
13161.CN
Nutrition and Foods (CN)
05007.CN
Administrative Medical Office Professional (CN)
09170.CM
Drone Technology (CM)
15400.AAT
Philosophy (AAT)
05008.AA
Administrative Office Professional (AA)
06100.AA
Digital Arts (AA)
10500.AA
Photography (AA)
05008.CT
Administrative Office Professional (CT)
09040.AA
Electronics: Computer & Networking Technology (AA)
10500.CN
Photography (CN)
01052.CN
Agricultural Chemicals (CN)
09040.CT
Electronics: Computer & Networking Technology (CT)
08500.AA
Physical Education (AA)
01050.AA
Agriculture (General) (AA)
09250.AA
Electronics: Electronics Technician (AA)
19700.AST
Physics (AST)
01050.CT
Agriculture (General) (CT)
09250.CT
Electronics: Electronics Technician (CT)
20500.AA
Psychology (AA)
01040.AS
Agriculture (General): Advanced (AS)
09510.AA
Electronics: Industrial Electrical Technician (AA)
20500.AAT
Psychology (AAT)
01000.AS
Agriculture Business (AS)
09510.CT
Electronics: Industrial Electrical Technician (CT)
12700.AS
Radiologic Technology: Diagnostic Rad Tech (AS)
01000.AST
Agriculture Business (AST)
09650.AA
Electronics: Instrumentation and Process Control Technology (AA)
12700.CF
Radiologic Technology: Diagnostic Rad Tech (CF)
01000.CT
Agriculture Business (CT)
09650.CT
Electronics: Instrumentation and Process Control Technology (CT)
22600.AA
Social and Behavioral Sciences (AA)
01100.AS
Animal Science (AS)
49810.AAT
Elementary Teacher Education (AAT)
22650.AAT
Sociology (AAT)
01100.CT
Animal Science (CT)
09300.AS
Engineering (AS)
12800.CT
Sonography: Diagnostic Medical Sonography (CT)
22000.AAT
Anthropology (AAT)
09350.AS
Engineering Technology (AS)
11600.AAT
Spanish (AAT)
10110.AA
Art (AA)
15200.AAT
English (AAT)
10550.AAT
Studio Arts (AAT)
09000.AS
Automotive Collision Repair (AS)
22200.AAT
Entrepreneurship: Economics (AAT)
10600.AAT
Theatre Arts (AAT)
09009.CN
Automotive Collision Repair (CN)
05700.AA
Entrepreneurship: Small Business Entrepreneurship (AA)
10600.AA
Theatre Arts (AA)
09010.CN
Automotive Technology Level 1 (CN)
05700.CT
Entrepreneurship: Small Business Entrepreneurship (CT)
09800.AA
Welding: Welding Technology (AA)
09002.CT
Automotive Technology Level 2 (CT)
01225.AS
Equine Science and Management (AS)
09810.CN
Welding: Welding Technology (CN)
09003.AS
Automotive Technology: Master Auto Technician (AS)
01225.CT
Equine Science and Management (CT)
09785.CE
Welding: Pipe Welding Technology (CE)
09008.CT
Automotive Technology: Master Auto Technician (CT)
21400.AS
Fire Technology (AS)
Adult Education & Noncredit
04100.AST
Biology (AST)
21400.CT
Fire Technology (CT)
04130.CN
Biotechnology (CN)
11200.AA
French (AA)
49165.NC
Basic Skills
04135.AS
Biotechnology-Industry (AS)
22250.AAT
Geography (AAT)
21078.NC
Court Interpreter
04137.AS
Biotechnology Pre Professional (AS)
19400.AST
Geology (AST)
49196.NC
ESL Beginning Skills Program
05150.AA
Business (General) (AA)
11400.AA
German (AA)
49198.NC
ESL Intermediate Skills Program
05150.CT
Business (General) (CT)
12300.AA
Health Sciences (AA)
49166.NC
Mathematics College Preparatory Basic Skills
05100.AST
Business Administration (AST)
22300.AAT
History (AAT)
49167.NC
Mathematics College Preparatory Basic Skills
19100.AST
Chemistry (AST)
21500.AA
Human Services (AA)
10100.NC
Medical Assistant
13010.AA
Child Development (AA)
21500.CT
Human Services (CT)
49199.NC
Reading and Writing College Preparatory Basic Skills
13010.AST
Child Development: Early Childhood Education (AST)
09401.AA
HVAC: Commercial Refrigeration Technician (AA)
07744.NC
Technical Office Occupations
13015.CT
Child Development: Early Intervention Assistant Specialization (CT)
09401.CT
HVAC: Commercial Refrigeration Technician (CT)
Certificates Not Transcripted
13020.CT
Child Development: Families in Crisis Specialization (CT)
09400.AA
HVAC: HVAC Technician (AA)
13026.CT
Child Development: Infant/Toddler Care (CT)
09400.CT
HVAC: HVAC Technician (CT)
05150.CE
Business Information Worker
13030.CT
Child Development: School Age Care Specialization (CT)
49200.CT
IGETC (Intersegmental Gen. Ed. Transfer Curriculum) (CT)
05200.CO
Customer Service Academy Certificate (CO)
15601.AAT
Communication Studies (AAT)
09550.AA
Industrial Maintenance Technology (AA)
12100.CE
Emergency Medical Technician (CE)
07200.AST
Computer Science (AST)
09550.CT
Industrial Maintenance Technology (CT)
12150.CO
Nursing Assistant (CO)
07300.AS
Computer Science: Management Information Systems (AS)
12400.AAT
Kinesiology (AAT)
09785.CE
Pipe Welding Technology
21150.AA
Criminal Justice (AA)
01350.AS
Landscape Horticulture (AS)
05600.CE
Real Estate Salesperson License (CE)
21150.CT
Criminal Justice (CT)
01350.CT
Landscape Horticulture (CT)
05725.CE
Social Media (CE)
21075.AST
Criminal Justice: Administration of Justice (AST)
49501.AA
Liberal Studies (Teaching Preparation) (AA)
05800.CE
Virtual Office Professional (CE)
01150.AA
Crop Science (AA)
05450.AA
Management/Supervisory Training (AA)
AA-T = Associate in Arts for Transfer
AS-T = Associate in Science for Transfer
AA = Associate in Arts (A.A.) degree
AS = Associate in Science (A.S.) degree
CE = Certificate requiring 6 to <18 semester units (Not approved by Chancellor’s Office)
CM = Certificate requiring 8 to <16 semester units (Approved by Chancellor’s Office)
CN = Certificate requiring 16 to <30 semester units
CT = Certificate requiring 30 to < 60 semester units
CF = Certificate requiring 60 or more semester units
CO = Other credit Award, under 6 semester units
01150.AS
Crop Science (AS)
05450.CT
Management/Supervisory Training (CT)
01150.CT
Crop Science (CT)
05460.AS
Marketing (AS)
49100.CT
CSU General Education (CSU GE Breadth) (CT)
05460.CT
Marketing (CT)
01200.AS
Diesel Equipment Technology (AS)
17400.AST
Mathematics (AST)
01200.CT
Diesel Equipment Technology (CT)
01450.AS
Mechanized Agriculture: Mech Ag Technology (AS)
13180.CN
Dietetic Services Supervisor (CN)
01450.CT
Mechanized Agriculture: Mech Ag Technology (CT)
09104.AS
Drafting: CAD Drafting – Architectural Design (AS)
01453.CN
Mechanized Agriculture: Compact Power Equipment (CN)
09105.AS
Drafting: CAD Drafting – Mechanical Design (AS)
10400.AAT
Music (AAT)
09101.AS
Drafting: CAD Draftsman – Architectural (AS)
10400.AA
Music (AA)
09102.AS
Drafting: CAD Draftsman – Mechanical (AS)
12500.AS
Nursing, Registered (AS)
09101.CN
Drafting: CAD Draftsman – Architectural (CN)
12550.AA
Nursing, Vocational (AA)
09102.CN
Drafting: CAD Draftsman – Mechanical (CN)
12550.CT
Nursing, Vocational (CT)
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Form 2020: Application for Admission (Merced College)

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Completed 2 February 2021

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