Last First Middle (if different)
Mailing Address City State Zip
__________________________________________________ _________________________________
Social Security Number Date of Birth (mm/dd/yyyy)
GENDER: MALE FEMALE OTHER HOME/CELL PHONE ______________________________________
COCC uses text messages for college emergencies & other important notifications
PERSONAL EMAIL: ________________________________________________ GRADUATION YEAR ___________
(required--high school issued email will not work)
PARENT’S EMAIL: ______________________________________________________________________________
Check the appropriate boxes that apply to you:
Ethnic origin: Do you consider yourself of Hispanic/Latino origin?
In addition, select one or more of following that apply:
NON-DISCRIMINATION POLICY: The goal of Central Oregon Community College is to provide an atmosphere that encourages our faculty, staff and students to
realize their full potential. In support of this goal, it is the policy of the Central Oregon Community College that there will be no discrimination or harassment on the
basis of age, disability, sex, marital status, national origin, ethnicity, color, race, religion, sexual orientation, gender identity, genetic information, citizenship status,
veteran status or any other classes protected under Federal and State statues in any education program, activities or employment. Persons having questions about
equal opportunity and non-discrimination should contact COCC’s Equal Employment Officer at 541-383-7219.
SS NUMBER: SOCIAL SECURITY NUMBER: Once your initial Application for Admission is processed, you will be assigned a COCC ID number. Use this number
to register for classes and other college related business. Providing your social security number (SSN) is voluntary. If you provide it, the College will use your SSN
for keeping records, research and reporting, extending credit, processing debts, IRS reporting and allowing students access to the COCC/ OSU Cascades library
systems. The College will not use your number to make any decision directly affecting you or any other person. Your SSN will not be given to the general public. If
you choose not to provide your SSN, you will not be denied any rights as a student. Please read the consent for information contained in the catalog, which describes
how your number will be used. Providing your SSN means that you consent to use of the number in the manner described.
Course registration on reverse
Release of Information: I authorize COCC to release information related to College Now courses and
programs to representatives of my high school, school district, and parents/guardians listed below. The
information released will be used for only the purposes of facilitating the College Now dual credit program.
I understand that revocation of this permission is my responsibility.
______________________________________________ _________________________________________
Please print parent(s) name(s)
_______________________________________________________________ ___________________
(Your signature gives COCC permission to follow the above Release of Information.)
Yes No
Black or African American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Other/No Answer
click to sign
click to edit
Questions? Check out our website: cocc.edu/departments/college-now
Still have questions? Email collegenow@cocc.edu or call 541.504.2930
High School
COCC ID Number (if known)
Last Name
First Name
Middle Initial
COCC Course Title
Course Number
Fee ($25 x credits)
CRN Section No.
COCC Use Only
*A separate registration form must be submitted for every College Now Course.