Fillable Student Information Form (Danville Area Community College)

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Student Information Form (Danville Area Community College)

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Student Information Form
Oce Use Only:
Name: __________________________________________________________________________________Student ID #: ________________________________
1. Name: (Please use your full name as it appears on your Social Security Card)
Salutation: (check one) Mr. Mrs. Miss Ms.
Last_____________________________ First______________________ Middle__________
Previous Name(s) ____________________________________________________________
Permanent Legal, Home Mailing Address: # and Street (Apt. #) or Rural Route & Box Number
_________________________________________________________________________
City ____________________ State (or Country)___________ Zip Code_________County_____________
2. Homeless: Are you Homeless? Yes No If Yes, please list an alternate mailing address above (in #1) for required
communications (financial aid, records and business office).
3. Foster Care System: Are you in the Foster Care System or have you aged out of the system? Yes No
4. Area Code & Phone #: Cell ( )_______________ Alternate ( )______________
Note: Cell phone numbers will be used for the Emergency Text Alert system. Students may opt out.
5. Social Security Number:___________ / _____________ /______________
**Social Security Number is a requirement for Federal reporting and possible tax deductions.**
**You will be assigned a DACC ID# for general use.**
6. Date of Birth: _____________________ 7. Gender: Female Male
8. Emergency Contact: _______________________________________________________________
Phone #____________________________ Relationship ____________________________________
10. Term you plan on starting in: (check one) Fall 20____ Spring 20____ Summer 20____
11. Program of Study / Major:___________________________________________________________
Career/Occupational (To prepare for work world) Personal Interest / No Degree or Certificate
Transfer/Baccalaureate (To prepare for transfer to four year college)
12. Admissions Status: High School Student Returning Student (Attended DACC Before)
New Student Corporate & Community Education Enrollee
New Transfer from another college
13. Educational Goal: Complete 1 or more course(s) Complete Certificate (30 plus hours)
Complete Certificate (1-29 hours) Complete Associate Degree
14. Citizenship or Visa:
U.S. Citizen Not on a Visa/Not a U.S. Citizen Permanent Resident (green card) Please attach copy.
In U.S. on a Visa. Type of Visa:_______________________________________ (Please attach copy.)
Country of Citizenship: __________________________________ Expiration Date of Visa: ______________
Applying for a Student Visa (Please note that we have a separate International Student Application.)
Month/Day/Year
REV 4/15/20
9. Ethnic/Race Classification: ( Providing the informaon below is voluntary and will not be used in a discriminatory manner.
These quesons comply with Federal Regulaon standards for ethnic and racial data collecon. )
a. Are you Hispanic or Latino? Yes No
b. Are you from 1 or more of the following racial/ethnic groups? (Select ALL that apply.)
American Indian or Alaskan native Black or African American White/Non-Hispanic
Asian or Pacific Islander Native Hawaiian or Pacific Islander
c. Please identify your primary racial/ethnic group (Select One)
American Indian or Alaskan native Black or African American White/Non-Hispanic
Asian or Pacific Islander Native Hawaiian or Pacific Islander
DANVILLE AREA
COMMUNITY COLLEGE
Alternate Number:
Please Check One
Other Cell
Landline
Work Number
SIGNED__________________________________________ DATE _____________
15. Armed Forces: Are either of your parents a member of the Armed Forces and on Active Duty? Yes No
16. Are you a veteran? Yes No
Are you a dependent of a veteran? Yes No
Is your spouse a veteran? Yes No
17. Institutions Previously Attended:
High School/High School Equivalency (GED) Information (check one)
Armstrong 13471 Danville 13834 High School Equivalency (GED) 37129 North Vermillion 36401 Schlarman 306
Bismarck 13518 First Baptist 13836 Hoopeston 14014 Oakwood 13928 Seeger 15089
Catlin 13579 Fountain Central 15063 Jamaica 14375 Rossville 14349 Shiloh 14015
Chrisman 13801 Georgetown-Ridge Farm 13956 Milford 14137 Salt Fork 157237 Westville 14479
Covington 14607 Other: ____________________________________________
High School: (check one) High School Equivalency (GED): (check one)
Currently in High School Currently in High School Equivalency
Expected Completion: ___________________ Expected Completion: ___________________
Graduated from High School: ___________________ Graduated from High School Equivalency: _________________
Did not Graduate Did not Graduate
List all Colleges/Universities previously attended or currently attending
Name of School City/State Attended From/To Date Graduated
__________________________________ _____________________ _____ / ______ _____ / _____
__________________________________ _____________________ _____ / ______ _____ / _____
18. Highest Previous Degree Earned: (check one)
None GED Certificate Certificate Bachelor’s Degree Doctoral Degree
High School Some College/No Degree Associate Degree Master’s Degree Other Unknown
19. Employment Status:
Employed Full-time Employed Part-time/15+ hours Employed Part-time/1-14 hours Homemaker
Unemployed/Retired Other No Response
20. Attendance Goal:
Transfer to 4 Year College Improve skills for job Prepare for job in future
Prepare for GED For personal interest Unknown
21. What is the highest degree/education level your mother/father/legal guardian completed?
22. Is English your native language? Yes No
23. Are you an Out-of-Workforce Individual? According to federal guidelines, an Out-of-Workforce individual is an individual who
a) has worked primarily without payment to care for a home/family and for that reason has diminished marketable skills; OR b) is a parent
whose youngest dependent child will become ineligible to receive assistance under part A of title IV of the Social Security Act (42 U.S.C. 601 et
seq.) not later than 2 years after the date on which the parent applies for assistance under such title; OR c) is unemployed or underemployed and
is experiencing difficulty in obtaining or upgrading employment. Yes No
24. Are you a single parent? According to federal guidelines, a single parent is either a single pregnant woman OR an individual who is
unmarried or legally separated from a spouse and has a minor child or children for which the parent either has custody or joint custody.
Yes No
NON-DISCRIMINATION STATEMENT: Danville Area Community College does not discriminate in educational opportunities, including career and technical educational opportunities, on the basis of
race, color, sex, religion, age, national origin, ancestry, marital status, unfavorable discharge from military service (except dishonorable), mental or physical disability unrelated to the ability to perform
essential program and job functions, veteran status, or any basis of discrimination precluded by the applicable federal and state statutes in its programs and activities. The College will take steps to
assure that the lack of English-language proficiency will not be a barrier to admission and participation in CTE programs. Career and technical education courses/program offerings and admission crite-
ria are on our web site, www.dacc.edu or by calling 217-443-3222. Inquiries regarding the non-discrimination policy are handled by Jill A. Cranmore, Director, Human Resources, Affirmative Action
Officer, Title IX Coordinator, and Section 504/ADA Coordinator at DACC, 2000 E. Main St., Martin Luther King Memorial Way, Danville, IL 61832-5199, 217-443-8756, or jcranmore@dacc.edu.
****I VERIFY THAT THE INFORMATION ON THIS FORM IS TRUE****
Month/Day/Year
Month/Day/Year
None High School Some College
Associate
Degree
Bachelor’s
Degree
Master’s
Degree or Higher
High School Equivalency
(GED)
Parent 1/Mother
Parent 2/Father
or Legal Guardian
Month/Day/Year
Month/Day/Year
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Student Information Form (Danville Area Community College)

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Completed 15 September 2020

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