Fillable REGISTRATION FORM Signatures Required As Indicated Below. Use (Columbia Basin College)

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REGISTRATION FORM Signatures Required As Indicated Below. Use (Columbia Basin College)

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REGISTRATION FORM
Use this form to complete a schedule change, late enrollment, audit, class overload and over 18 credit requests.
Signatures required as indicated below.
TO BE COMPLETED BY THE STUDENT:
Quarter: all Winter Summer F Spring Year:
SID #:
Last Name: First Name: MI: Male Female
Cell Phone #: Other Phone #: Birth Date:
Address: City: State: Zip:
ITEM # COURSE ID
# OF
CREDITS
PUT AN “X” IN THE
APPROPRIATE BOX
INSTRUCTOR APPROVAL (INITIAL AND DATE)
INSTRUCTOR SIGNATURE
ADD DROP AUDIT LATE ENROLLMENT OVERLOAD CAPACITY DATE
Over 18 Credits Advisor Signature: Date:
Financial Aid Disclaimer: I wish to make a change to my schedule as noted above and understand that making this change may aect my financial aid in adverse ways (ie: loss of future
financial aid, owe money back to the College, etc). I further understand that I should speak with a Hawk Center Specialist prior to processing.
LIMITATION OF LIABILITY: The College’s total liability for claims arising from a contractual relationship with the student in any way related to classes of programs shall be limited to tuition
and expenses paid by the student to the college for those classes or programs. In no event shall the college be liable for any special indirect, incidental, or consequential damages, including
buy not limited to, loss of earnings or profits.
Student Signature: Date:
For Ocial Use Only
Processor Signature: Date:
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and afrmative action. CBC does not discriminate on the basis of race, color, creed, religion, national or ethnic ori-
gin, parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information, honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or ser-
vice animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment. Questions or complaints may be referred to the Vice President for Human Resources & Legal Affairs and CBC’s Title IX/EEO Coordinator at (509) 542-5548. Individ-
uals with disabilities are encouraged to participate in all college sponsored events and programs. If you have a disability, and require an accommodation, please contact the CBC Resource Center at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request.
Select only one best response for the following questions.
How long do you plan to attend Columbia Basin College?
11 er
12 Two quarters
One quart
13 One year
14 Up to two years, no degree planned
15 Long enough to complete a degree
16 Don’t know
90 Other
What is your current work status while attending college?
11 Full-time homemaker
12 Full-time employment (including self-employed and military)
art-time o-campus
13 P
14 Part-time on-campus
15 Not employed, but seeking employment
16 Not employed, not seeking employment
90 Other
What is your prior level of education at entry to Columbia Basin College?
11 Less than high school graduation
12 GED
13 High school graduate
14 Some post high school, but no degree or certificate
15 Certificate (less than two years)
16 Associate's degree
17 Bachelor’s degree or above
90 Other
What was your family status when you started at Columbia Basin College?
11 A single parent with children or other dependents in your care
12 A couple with children or other dependents in your care
13 Without children or other dependents in your care
90 Other
How long have you resided in Washington state?
Years
evious calendar year? Yes
Months
Were you financially independent from your parent or legal guardian for the
pr No
If NO, how long has your parent or legal guardian resided in Washington state?
Years
Are you active duty military
Months
, spouse or dependent child of same? Yes No
If YES, when was the active duty military person first stationed in Washington?
Month
Day Year
Are you a higher education employee or dependent? Yes No
Yes No
Last High School Attended City State Year Graduated
Yes No
Last College Attended City State Year Graduated
What is your main long-term goal for attending Columbia Basin College?
o current or future work 11 Take courses related t
12 Transfer to a four-year college
13 High school diploma or GED
14 Explore career direction
15 Personal enrichment
90 Other
Please mark one or more boxes to indicate
Kor 12)
what r
e (Please specify)
ean (6
ace you consider yourself to be.
Japanese (611)
Other Asian (621)
White (800)
Other Rac
African American (870)
American Indian (597)
Are you of Spanish/Hispanic origin?
Alaskan Native (015)
No (999)
Native Hawaiian (653)
xican, Mexican American, Chicano Yes, Me
Other Pacific Islander (681)
(722)
Vietnamese (619)
Yes, Puerto Rican (727)
Filipino (608)
Yes, Cuban (709)
Chinese (605)
Yes, Other Spanish/Hispanic/Latino
Please specify
Gold Card (60 yrs and older) Senior Fitness Only (55 to 59 yrs)
Driver’s License/ID Required
Community User - Fitness Center Only
Please complete the box below.
If NOT a U.S. Citizen, what is your immigration status?
Student (F-1) Visitor Immigrant/Permanent Resident (IM)
Other
For Official Use Only
Student Intent Codes:
H --- Occupational Apprentice
J --- Occupational Supplement
A --- General Studies Degree or Certificate
K --- Vocational Home and Family Life
B --- Academic Transfer
L --- General Studies (no degree or certificate)
D --- High School Diploma/GED Certificate
W --- Community Service
E --- Development
X --- Undecided
F --- Occupational Preparatory
Y --- None of the above
G --- Occupational Preparatory Applicant
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REGISTRATION FORM Signatures Required As Indicated Below. Use (Columbia Basin College)

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Completed 21 July 2020

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