.
PROGRAM NAME CODE (THE LISTING OF CCAC
PROGRAM CODES ON PAGE 8)
SIGNATURE DATE
ADVISOR COMMENTS
ADVISOR SIGNATURE DATE STUDENT SIGNATURE DATE
I agree that once I register I become legally bound by and agree to the terms of the Community College of Allegheny County Student Financial Responsibility Agreement, and as such become
responsible for all charges incurred, unless I drop classes during the designated refund period. I understand that the college is extending credit to me and permitting me to register, enroll and
attend classes in return for my promise to pay the college all tuition and fees incurred as a result of my registration, and that such extension of credit constitutes an educational loan or education
benet that is non-dischargeable under Section 523 (a)(8) of the United States Bankruptcy Code. I understand that failure to pay my student account or any monies due and owing CCAC may
result in a nancial hold placed on my account preventing registration for future classes, release of transcripts and diplomas, and additional college services. Additionally I understand that failure
to pay my student account or any monies due and owing CCAC will result in a $15.00 late payment fee assessed to my account for each late payment and may result in my account being referred
to a third party collection agency resulting in additional fees. Finally, I understand that all delinquent student accounts may be reported to one or more of the national credit bureaus.
The college is subject to provisions of and complies with the Family Educational Rights and Privacy Act of 1974. A statement of the college policy can be found in
the student handbook and college catalog (online at ccac.edu).
If you are registering for an Online Learning course, visit ccac.edu/online-getting-started.
COURSE TITLE TERM EXPRESS CODE
CATALOG
COURSE NO.
SECTION
TIME DAYS
LOCATION CREDIT AUDIT
FROM TO U M T W R F S
Returning students may also register at my.ccac.eduCCAC REGISTRATION FORM
Preferred Home Campus
Allegheny (North Shore)
Homewood-Brushton Center
Boyce (Monroeville)
Braddock Hills Center
North (McCandless)
West Hills Center
South (West Mifin)
Washington County Center
Ethnicity & Race**
Hispanic/Latino/Spanish Origin: Yes No
Select all that apply:
American Indian or Alaskan Native (including all Original Peoples of
the Americas
Asian (Including Indian subcontinent & Philippines)
Black or African American (including Africa & Caribbean)
Native Hawaiian or Pacic Islander (Original Peoples)
White (including Middle Eastern)
I choose not to reply
Gender** Male Female
Marital Status** Married Single
Voluntary Information (Please check one in each section.)
Providing the information below is optional. This voluntary information is used
to comply with federal reporting and has no effect on admission to the college.
Have you served in the military? Yes No
Are you a dependent of a veteran/military member? Yes No
Citizenship Status (Check One)
United States Citizen Permanent Resident
Non-resident/ International Student Other
Residency Status (Check One)
Domicile shall mean a person’s true, xed and permanent home, to which one intends
to return after being absent.
In Allegheny County
Out-of-state
Out of Allegheny County with
Community College
BIRTHDATE (MM/DD/YY)
LAST NAME FIRST NAME MIDDLE INITIAL
STREET ADDRESS APARTMENT NUMBER
CITY STATE ZIP CODE COUNTY
EMAIL ADDRESS CELL PHONE HOME PHONE BUSINESS PHONE
(IF STUDENT ID NUMBER UNAVAILABLE)
STUDENT IDENTIFICATION NUMBER
SOCIAL SECURITY NUMBER
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