Updated 03/4/2015
The following information will help Minnesota State Colleges and Universities evaluate student recruitment and retention policies; it
will not be used as a basis for admission. Providing this information is voluntary.
Gender: __ Female __ Male
Are you Hispanic or Latino? □ Yes □ No
(A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American or other Spanish culture, regardless of race)
Race and ethnic background - Please select all that apply:
___ American Indian or Alaska Native (A person having origins in any of the original peoples of North, Central or South America and who
maintains 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 American (A person having origins in any of the black racial groups of Africa)
___ Native Hawaiian or 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 ordinal peoples of Europe, the Middle East or North Africa)
___ Two or More Races
CONFIDENTIAL INFORMATION
Supplemental Documents
By initialing each item below, I verify that all required materials listed below have been are being submitted along with my
application.
_____ MN Department of Education Notice of Student Registration with signatures from student, parent/guardian, and high school
(initials) official.
_____ Official High School Transcripts (in a sealed envelope from the school). Transcripts must include the most recent semester grades
(initials) as well as 8
th
grade MN Comprehensive Assessment (MCA) test results.
_____ NHCC PSEO Agreement of Understanding found at www.nhcc.edu/pseo has been thoroughly reviewed (does not need to be
(initials) submitted to NHCC).
Signature
In signing this application, I certify that the information I have provided on this application form and in all other admission application materials is
complete, accurate and true to the best of my knowledge. I also certify that I have thoroughly reviewed and agree to all of the items listed on the PSEO
Career/Technical Education Program Restrictions and on the PSEO Agreement of Understanding.
Applicant’s Signature: ____________________________________________________________ Date: __________________________
Access to Student Records
Required The college will not permit access to or the release of personally identifiable information contained in student educational records without the written consent of the student to any third party, except as authorized by the
MGDPA and FERPA or other applicable law. A copy of the Release of Private Educational Data form is available in Student Services offices, academic areas, and the college Information Drive. A written consent is valid if it: 1)
specifies the records that may be disclosed; 2) states the purpose of the disclosure; 3) identifies the person(s) to whom the disclosure may be made; and 4) is signed and dated by the student. If the release is for disclosure to an
insurer or its representative, the release must also include an expiration date no later than one year from the original authorization, or two years for a life insurance application. If the student requests, the school shall provide him or
her with a copy of the records released pursuant to the informed consent.
NHCC is a member of the Minnesota State Colleges and Universities System and an Equal Opportunity Educator and Employer.
For disability accommodations call 763-493-0555. Minnesota Relay users may call 1-800-627-3529.
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