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154 | PHOENIX COLLEGE SUMMER AND FALL 2011 SCHEDULE EZINE PUBLISHED ON 03/21/2011 | FOR CURRENT CLASS SCHEDULE UPDATES VISIT MY.MARICOPA.EDU Student Information Form 1202 W. Thomas Road Phoenix, Arizona 85013 602-285-7777 602-285-7813 Fax Student ID#______________________Term of Enrollment: Fall Spring Summer I Summer II Year____________ Legal Name ______________________________________________________________________________________________ Date of Birth _________________________ Gender ** M F Social Security Number_______________________ Your Social Security Number will not be used as your primary student identification number and will be kept confidential. Providing a Social Security Number will ensure that your educational records are complete and correct and will allow the fullest services. Any individuals that wish to gain full access to Maricopa’s secure online self-services resources must provide both the Social Security Number and date of birth. Students should be aware that a correct Social Security Number must be on file for reporting information pertaining to potential tax credit, and must be used by applicants for federal and state aid, and Veteran Administration benefits. Failure to provide a correct Social Security Number may preclude the determination of eligibility for in-state residence, resulting in out-of-state tuition. Information Release Do you give permission for the college to release directory information relative to your enrollment (as per the Family Education Rights and Privacy Act of 1974)? Yes No ADDRESS INFORMATION Address _____________________________________________________________________________________________ Apt# _______________ City _____________________________________________________________________________ State _________ Zip ____________________ Telephone Number: Home ______________________________________________ Other _____________________________________________ Email Address: Home ___________________________________________________ Other _____________________________________________ RESIDENCY* US Citizen Legal Immigrant/Permanent Resident Lawful Refugee or Asylee Legal Nonimmigrant APPLICANT INFORMATION Last First Middle DEMOGRAPHIC INFORMATION Date of Issue___________________ Expiration Date_______________ _Alien Registration#________________________ Date of Issue___________________ Expiration Date _______________ Alien Registration#________________________ Specify Visa or staus ___________________________________ Date of Expiration of I-94__________________________ Alien Registration Number or I-94 Number_________________________________________________________________ Do Not Qualify for Any of the Above Country of Citizenship _______________________________________________________ AZ Department of Motor Vehicle License or ID Number_______________________ Date of Issue_________________Expiration Date________________ Do not possess an AZ Department of Motor Vehicle License or ID Number * These questions are asked for the purpose of determining tuition and fees. State law now requires that a person who is not a citizen or legal resident of the United States or who is without lawful immigration status is not entitled to classification as an in-state student pursuant to A.R.S. Section 15-1802 or entitled to classification as a county resident pursuant to A.R.S. Section 15-1802.01. Failure to answer the above questions may result in being classified as out-of-state for tuition and fee purposes. The responsibility of registering under the proper residency classification is placed upon the student. Any student who falsifies his/her residency shall be required to pay full tuition and may be subject to dismissal from the college and/or criminal action. Refer to the college catalog for residency guidelines. RACE/ETHNICITY** This is a two part question: Do you consider yourself to be Hispanic/Latino? Yes No If yes, which Ethnic Group?_________________________________ If you responded YES to the above and are of more than one race, select from additional ethnic categories below. If you responded NO, please select one or more of the following racial/ethnic categories to describe yourself. If selecting more than one, please indicate which ethnic category you consider as your primary category. You may also include details regarding your ethnic group or Native American tribe if applicable. Category Primary Y/N Ethnic Group/Tribe American Indian/Alaska Native _______ ____________________________________ Asian _______ ____________________________________ Black or African American _______ ____________________________________ Native Hawaiian or other Pacifi c Islander _______ ____________________________________ White _______ ____________________________________ ** Voluntary information used to comply with Federal Reporting and has no effect on admission to the college. This information will not be used for any discriminatory purpose. PREVIOUS EDUCATION High School Status (check one box) High School Diploma High School Name __________________________________________ State ___________ Completion Date ________________________ SAIS NUMBER _______________________________ Arizona Department of Education (ADE) Student Accountability Information Systems (SAIS) Number GED Certificate Completion Date ___________________________________ Currently Enrolled High School Name __________________________________ State __________ Expected Completion Date _______________________ Home Taught Expected Completion Date _____________________________________ No diploma or GED and under age 18 No diploma or GED and over age 18 Previous College (check highest level completed) Associate Degree Bachelor Degree Master Degree or higher No College or University Some College/University, no degree FIRST GENERATION COLLEGE STUDENT Are you a first generation college student? Yes No You are a first generation student if both parents or guardians (parent or guardian if only living with one) did not complete a bachelor’s degree. The Maricopa County Community College District is an EEO/AA institution. Continued on back...
PHOENIX COLLEGE SUMMER AND FALL 2011 SCHEDULE EZINE | 155 FOR CURRENT CLASS SCHEDULE UPDATES VISIT MY.MARICOPA.EDU | LANGUAGE BACKGROUND What was the first language you spoke as a child?___________________________________________________________________ What languages were spoken in your home when you were growing up?_________________________________________________ What language do you speak most often now?______________________________________________________________________ Do you wish assistance with English fluency skills? Yes No PLEASE CHECK ONE OR MORE IF YOU NEED HELP WITH... Financial Aid Study Skills Personal Concerns Commuter Information <strong>Find</strong>ing Work Writing Skills Learning Disability*** Work Experience Credit Learning English Math Skills Physical Disability*** Childcare Information Reading Skills Choosing a Major or Career Health Problems Mentoring Other____________________________ *** If you require assistance or accommodation to participate fully as a student, please contact Disability Services and Resource (DSR) EMPLOYMENT HOURS Employment hours planned per week while enrolled: 1-10 hours 11-15 hours 16-20 hours 21 - 30 hours 31 or more hours None MILITARY Are you currently a member of the US Armed Forces stationed in Arizona pursuant to military orders? Yes No Are you a dependent of a member of the US Armed Forces stationed in Arizona pursuant to military orders? Yes No Are you a Veteran of the US Armed Forces? Yes No RESIDENCY Final residency decisions for tuition purposes will be made in accordance with A.R.S. 15-1801 and regulations of the Maricopa Community College Governing Board. Will you reside in Arizona at the time of attendance? Yes No What date did your present stay in Arizona begin? Month_______________________ Day____________________ Year__________________ What was your most recent state of residence prior to moving to Arizona? _______________________________________________ In what Arizona county do you reside?____________________________________________________________________________ If Maricopa, what date did you move to this county? Month_______________________ Day____________________ Year__________________ What Arizona county did you reside in prior to moving to Maricopa County? ______________________________________________ Are you seeking admission under the Western Undergraduate Exchange program? Yes No If yes, in which state do you currently reside? ___________________________________________________________________ HOW DID YOU HEAR ABOUT THIS COLLEGE? Advertisement Agency Referral Application - Quick Admit Billboards Brochure Bus Stop Billboards Career Fair Cross College Direct Mail Email Fax Flyer Friend/Relative Group HS Counselor HS Recruitment Tour High School Referral International Recruitment Internet Military Recruiter Newspaper Ad Off-Site Other <strong>Out</strong>reach Event Phone Radio Ad Recruiter Schedule of Classes School Counselor Student TV Theatre Screen Advertisement Word of Mouth Yellow Pages EDUCATIONAL PLAN Primary reason for attending this college: Improve my career skills Learn new career skills Personal Interest/Self Improvement Prepare for a career change Prepare for employment Transfer to a University/College Transfer within MCCCD Transfer to University/MCCCD College: ____________________________________ Name of Transfer Institution VEHICLE EMISSIONS ________________________________ Area of Study Car meets emissions standards Will not park on campus For crime statistics reported under the Jeanne Cleary Disclosure of Campus Security Policy and Campus Crime Statistics Act, please visit www.maricopa.edu/safety ACADEMIC PLAN What academic plan do you intend to earn from this college? Degree Name __________________________ Code: _______ Certificate Name __________________________ Code: _______ I CERTIFY THAT THE ANSWERS ON THIS STUDENT INFORMATION FORM ARE TRUE, CORRECT AND COMPLETE. ________________________________________________________ ______________________________________________ Signature of Student ALL OF THE INFORMATION ON THIS FORM IS CONFIDENTIAL AND IN COMPLIANCE WITH THE FAMILY EDUCATION RIGHTS AND PRIVACY ACT OF 1974. THE ACT’S PROVISIONS ARE EXPLAINED IN THE GENERAL CATALOG. Date revised 01/10
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Summer & Fall 2011 Schedule -eZine
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Contents Academic Policies and Prac
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Get Your Student ID (Cub Card) 2 Ta
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Beartrax Workshop Sessions BearTrax
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March 21 • Registration begins Au
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PHOENIX COLLEGE SUMMER AND FALL 201
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Class Index continued W 122 Women's
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Fitness Center 602.285.7295 Fitness
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@ SURPRISE Your pathway to a better
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Page 139 and 140: $109 $109 0 $109 ONLINE200-10035 ED
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Page 147 and 148: Mathematics Flowchart PHOENIX COLLE
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Page 165: Phoenix College Vision Phoenix Coll
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