Fillable PERSONAL DATA SHEET (BOTH SIDES TO BE COMPLETED (Northland Community and Technical College)

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PERSONAL DATA SHEET (BOTH SIDES TO BE COMPLETED (Northland Community and Technical College)

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PERSONAL DATA SHEET
(BOTH SIDES TO BE COMPLETED EACH COLLEGE YEAR OF ENROLLMENT)
The College is asking you to provide information on the Personal Data Sheet, which includes private information under State and Federal law. The
private information is marked Voluntary Information on the form. The College uses this information to report various statistics about our student body
composition to campus, college, as well as State and Federal entities that request the information. You are not legally required to provide the
information the College is requesting and you may refuse to provide some or all of the information requested.
Name: ________________________________________________________________________________________
Last First Middle Initial
_______________________________________________________________________________________________
Street Address City State Zip
State of Residency: _____________________________________ Years of Residency: ____________
Phone Number: ____________________________________
Program at NCTC: ___________________________________________________________________
Name of Emergency Contact: _______________________________________________________________
Permanent Address of Emergency Contact: ____________________________________________________
Phone Number of Emergency Contact: ________________________________________________________
Student Signature____________________________________________ Date_________________________
VOLUNTARY INFORMATION
Last 4 digits of SSN: ___________________ Birth Date: _________________Gender: ____ Male ____ Female
Are you Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture, regardless of race)? Yes
No
Racial Background (select one or more)
American Indian or Alaska Native- A person having origins in any of the original peoples of North and South
America (including Central America) who maintains cultural identification through tribal affiliation or community
attachment.
Asian- A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian
subcontinent.
Black or African America- A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander- A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
White- A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
___________Single Parent - An individual who is unmarried or legally separated: AND has a minor child or children for whom the
parent has either physical custody or joint physical custody: OR is single and pregnant.
__________Displaced Homemaker – An individual who has worked primarily without pay to care for a home and family, and for that
reason has diminished marketable skills and is unemployed or underemployed and is experiencing difficulty in obtaining or
upgrading employment and at least one of the following is true:
- has been dependent on the income of another family member but is no longer supported by that income or
- is a parent whose youngest dependent child will become ineligible to receive assistance under part A of title IV of
the Social Security Act not later than 2 years after the date on which the parent applies for assistance under this
title.
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PERSONAL DATA SHEET
(BOTH SIDES TO BE COMPLETED EACH COLLEGE YEAR OF ENROLLMENT)
Students at Northland Community and Technical College must be aware of the information that is collected for their
student files, the purpose of the information, and consequences of providing or failing to provide the data. Please look
over the information below and sign the bottom of this form acknowledging that you are aware of the information that is
kept in your student file.
TYPES OF INFORMATION:
1. Diploma and transcripts from previous institutions
2. Institutional evaluation and assessment data
3. Admission applications, enrollment data, and support documentation
4. Authorization to release information, may include agency information
5. International student documents
6. Grades
7. Evaluations and instructor recommendations
8. Documents relating to student status regarding honors, probation, disciplinary hearings, and suspensions
Students will be allowed access to their records. Please see “Release of Student Information,” and “Directory Information”
in the Data Privacy Policy found in the Student Handbook online at
http://www.northlandcollege.edu/handbook/. In addition; any State, Federal, Government agency, Northland Community
and Technical College administration, student services staff, and instructors have access to the information in the file as
necessary to assist students in the successful completion of program requirements and gaining employment.
I understand the data collected and its intended use. If I want any other individual or agency to access my student file, I
must request this in writing to the campus registrar’s office or by completing the Consent of Information Release form.
___________________________________________/_____________________
Signature Date
ADVISOR/COUNSELOR/PROGRAM DIRECTOR CONTACT/DEVELOPMENTAL COURSEWORK
I understand that I need to contact my assigned advisor/counselor/program director within the first five (5) days of the
semester in order to make any necessary changes in my schedule.
I also understand that if I am required to complete developmental coursework, my program may be extended.
____________________________________________/_____________________
Signature Date
NORTHLAND COLLEGE EMAIL ACCOUNT
I understand that the official means of communication is through the Northland College email. Once I am a registered
student, this will be the primary means of notification of important announcements, news, and deadlines for me to access.
____________________________________________/_____________________
Signature Date
____________________________________________________________________/__________________________
(Print Name) (Star ID/Student ID-If Known)
1/14/2020 bgh
Northland Community and Technical College is an affirmative action, equal opportunity employer and educator.
This document is available in alternative formats to individuals with disabilities, consumers with hearing or speech disabilities may contact us via their
preferred Telecommunications Relay Service by dialing 711 (toll-free nationwide).
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PERSONAL DATA SHEET (BOTH SIDES TO BE COMPLETED (Northland Community and Technical College)

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Completed 26 July 2020

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