PA-OEC_CERegistrationAppEnglish- 7/06/2020-EVIDCS5.5

I HAVE ATTENDED RSCCD: Last term First term Returning after an absence

DATE ___________________________________________________

(Please Print)I . . . . . . . . . . . . . . . . . . . I I . . . . . . . . . . I I . . . . . . . . . . I I . . . . . . . . . . . . . . I

RANCHO SANTIAGO COMMUNITY COLLEGE DISTRICT

CONTINUING EDUCATION

Last Name

BIRTHDATE: __________ /__________ /__________

First Name

_______________________ _ ___

STREET ADDRESS: _____________________________________________ _ CITY _____ _ ____ STATE __________ ZIP CODE________________

The Rancho Santiago Community College District is committed to equal opportunity in educational programs, employment, and all access to institutional programs and activities. The District, and each individual who represents the District, shall provide access to its services, classes, and programs without regard to national origin, religion, age, gender, gender identity, gender expression, race or ethnicity, color, medical condition, genetic information, ancestry, sexual orientation, marital status, physical or mental disability, pregnancy, or military and veteran status, or because he or she is perceived to have one or more of the foregoing characteristics, or based on association with a person or group with one or more of these actual or perceived characteristics. The Chancellor shall establish administrative procedures that ensure all members of the college community can present complaints regarding alleged violations of this policy and have their complaints heard in accordance with the Title 5 regulations and those of other agencies that administer state and federal laws regarding nondiscrimination.

No District funds shall ever be used for membership, or for any participation involving financial payment or contribution on behalf of the District or any individual employed by or associated with it, to any private organization whose membership practices are discriminatory on the basis of national origin, religion, age, gender, gender identity, gender expression, race, color, medical condition, genetic information, ancestry, sexual orientation, marital status, physical or mental disability, pregnancy, or military and veteran status, or because he or she is perceived to have one or more of the foregoing characteristics, or because of his or her association with a person or group with one or more of these actual or perceived characteristics. Inquiries regarding compliance and/or grievance procedures may be directed to District’s Title IX Officer and/or Section 504/ADA Coordinator. RSCCD Title IX Officer and Section 504/Coordinator, 2323 N. Broadway, Santa Ana, CA 92706, 714-480-7490.

NONDISCRIMINATION POLICY

4 7 8

2

3

5

6

I certify that the information on this form is true and correct and I agree to comply with the RSCCD Student Conduct policies as a continuing education student.

Student Signature

1 2 3 4 5 6 7 8 910 11 12 13 14 15 16

RACE

____ AC - Chinese ____ AN - American Indian/Alaskan Native ____ AI - Asian Indian ____ AJ - Japanese ____ AK - Korean ____ AL - Laotian ____ AM - Cambodian ____ AV - Vietnamese____ AX - Asian Other ____ BL - Black or African American ____ FI - Filipino ____ PG - Pacific Islander Guamanian ____ PH - Pacific Islander Hawaiian ____ PS - Pacific Islander Samoan ____ PX - Pacific Islander Other ____ WH - White

____ HM - Mexican, Chicano ____ HR - Central American ____ HS - South American ____ HX - Hispanic Other

(check all that apply)

____ NHS - Not Hispanic or Latino ____ HIS - Hispanic or Latino

NATIVE LANGUAGE (check one only)

____ CA – Cambodian____ TA - Tagalog ____ KO - Korean ____ RU – Russian____ FA - Farsi____ AR - Arabic____ SO - Somali____ HM - Hmong____ OT - Other _______________

2 (check one)

___ 1) 0 -12,760___ 2) 12,761 – 17,240 ___ 3) 17,241 – 21,720 ___ 4) 21,721– 26,200 ___ 5) 26,201 – 30,680 ___ 6) 30,681 – 35,160 ___ 7) 35,161 – 39,640 ___ 8) 39,641 - 44,120 ___ 9) 44,121 - 48,600 ___ 10) 48,601 - 53,080 ___ 11) 53,081 - 57,560 ___ 12) 57,561 - 62,040 ___ 13) 62,041 or more

NUMBER IN HOUSEHOLD(enter a number)

(check all that apply)

WITHIN PROGRAM YEAR

OFFICE USE ONLY CASAS

needed New Readmit

. . . . . . . .Student Number

___________________ _______________District Clerk Date

YEAR 20 21 FALL

SPRING

SUMMER

Academic Program (Certificate or Diploma):

SOCIAL SECURITY #:__________________

0

EARNED

____ 1) H.S. Diploma____ 2) HSE Certificate (GED) ____ 3) Some college, No Degree ____ 4) Technical / Certificate ____ 5) A.A. / A.S. Degree ____ 6) 4 Year College Graduate ____ 7) Higher Than BA/BS ____ 8) None

4

( ______ ) PHONE #: (_____)

GENDER:

____1) US Citizen___2) Student VISA (F-1,M-1) ___3) Permanent Resident___4) Refugee, Asylee___5) Other

E

HIGH SCHOOL DIPLOMA

OTHER _____________________________

____ GJ - Get a Job ____ RJ - Retain Job ____ H - Advance in current Job ____ E - Earn Vocational Certificate ____ EC - Enter College or Training ____ F - Formulate Career Interest ____ FG - Family Goal ____ G - Prepare for a New Career ____ IE - Improve English Skills ____ J - Educational Development ____ K - Improve Basic Skills ____ L - H.S. Diploma / GED ____ MIL - Military coursework ____ N - Enroll in a college credit course ____ PER - Personal Goal ____ US - U.S. Citizenship ____ WP - Work-based Project

TERM SECTION # SECTION/COURSE TITLE SITE/ROOM DAY(S) START TIME END TIME TERM SECTION # SECTION/COURSE TITLE SITE/ROOM DAY(S) START TIME END TIME

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07/27/

2020

12:

15 P

M