PLEASE PRINT
List colleges, universities, etc. that you previously attended.
Social Security Number Date of Birth
As shown on social security card:
Last Name
Month Day Year
Name State Dates Attended
Name State Dates Attended
First Name Middle/Former
Mailing Address
Disadvantaged:
If any of the following apply to you, please check.
Other information:
City State Zip Code County
Home Phone ( ) Business Phone ( )
(E) ☐ Receive assistance (AFDC, Food Stamps, etc.)
(A) ☐ High school dropout (with or without GED)
Indicate Special Needs
(Y) ☐ English as second language
(H) ☐ Homemaker (has not recently worked outside the home)
(S) ☐ Single Parent
(FG) ☐ Are you the first person in your family to attend college?
For Statistical Purposes Only (Voluntary)
When Do You Plan To Attend HCC? Check one:
☐ Fall
☐ Spring
☐ Summer
(CR) ☐ None of the above
Parent Information
Please check highest degree completed by parent
Employment Information
1 ☐ Retired 5 ☐ Employed 11 - 20 hours per week
2 ☐ Unemployed - not seeking employment 6 ☐ Employed 21 - 39 hours per week
3
☐ Unemployed - seeking employment 7 ☐ Employed 40 or more hours per week
4 ☐ Employed 1 - 10 hours per week
Long Term Goal
1
☐ To obtain an associate degree, diploma, or certificate 4 ☐ To take courses to transfer to another college
2
☐ To enhance my job skills in my present field of work 5 ☐ To take courses for personal enrichment or
3 ☐ To enhance my employment skills for a new field of work interest
Father:
☐ Never Attended ☐ Tenth Grade
☐ Second Grade ☐ Eleventh Grade
☐ First Grade ☐ Completed High School
☐ Third Grade ☐ GED Diploma
☐ Fourth Grade ☐ Adult High School Diploma
☐ Fifth Grade ☐ One Year Vocational Diploma
☐ Sixth Grade ☐ Associate Degree
☐ Seventh Grade ☐ Bachelor’s Degree
☐ Eighth Grade ☐ Master’s Degree or Higher
☐ Ninth Grade
Mother:
☐ Never Attended ☐ Tenth Grade
☐ Second Grade ☐ Eleventh Grade
☐ First Grade ☐ Completed High School
☐ Third Grade ☐ GED Diploma
☐ Fourth Grade ☐ Adult High School Diploma
☐ Fifth Grade ☐ One Year Vocational Diploma
☐ Sixth Grade ☐ Associate Degree
☐ Seventh Grade ☐ Bachelor’s Degree
☐ Eighth Grade ☐ Master’s Degree or Higher
☐ Ninth Grade
1.
☐ Yes ☐ No Are you a U.S. citizen?
Resi
dency Information
Colleges and universities are asked by many, including the federal government, accrediting associations, college guides, newspapers, and our own college/
university communities, to describe the racial/ethnic backgrounds of our students and employees. In order to respond to these requests, we ask you to
answer the following two questions:
Do you consider yourself to be: Hispanic/Latino ☐ Yes ☐ No
2. ☐ Yes ☐ No Are you a resident of North Carolina?
3. ☐ Yes ☐ No Have you lived in North Carolina for the past 12 months? Since
Month Year
If not, why?
List dates outside North Carolina:
From: To: State
Educational Information
High School last attended
In addition, select one or more of the following racial categories to describe yourself:
☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American
☐ Native Hawaiian or other Pacific Islander ☐ White
Emergency Contact Information
PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name
Date of graduation or withdrawal
Name
County
State
Relationship
Mo/Yr
Mo/Yr
Home Address
Check Highest Degree Completed:
☐ Currently enrolled in high school
☐ GED Certificate
Place State
Month Year
Circle Highest Grade Completed: 8 9 10 11 12 over 12
☐ 12 High School Diploma
☐ 13 Adult High School
☐ 14 Post High School Vocational (1-year diploma)
☐ 15 Assoc./Assoc. in Applied Science (2-year)
☐ 16 Bachelor’s Degree
☐ 17 Masters or higher
Telephone
Business Address
Telephone
In case of emergency, permission is granted to seek medical assistance. ☐ Yes ☐ No
Signature
PLEASE COMPLETE REVERSE SIDE
