Pre-unit, Worksheet 2

Pre­Unit Worksheet 2

Name: Date:

Canyon County College ADMISSION APPLICATION YEAR ______

(check one) ___FALL

___SPRING

___SUMMER

INSTRUCTIONS: Type or print. Answer every question by filling in appropriate boxes or writing information required. Failure to do so will delay your registration. 1. ________________________

___________________

Last Name

2. ________________

Middle Name

3. Date of Birth ____/____/____ ___

Mother’s Maiden Name

5. (____) _____-_______

________________

First Name

Mo Day Year

4. _____-____-_____

Age

Social Security Number

6. Place of Birth ________________________

Area Code Telephone Number

City, State or Foreign Country

7. Sex (check one) ___Male ___Female

8. CURRENT ADDRESS ___________________________________ _________________________ Number and Street / Apt # City State

_____

_____________ Zip

9. WHEN DID YOUR PRESENT STAY IN CALIFORNIA BEGIN?______ /______ /______ Mo

Day

Year

List previous residence if current address is less than 2 years. ____________________ / ________ ________ to ________ City State Mo/Yr Mo/Yr ____________________ / ________ ________ to ________ City State Mo/Yr Mo/Yr ____________________ / ________ ________ to ________ City State Mo/Yr Mo/Yr

10. WHAT IS YOUR EDUCATIONAL GOAL? (check one only) ___Vocational Certificate ___BA/BS Degree after earning Associate Degree ___Maintain certificate or license (e.g. Nursing, Real Estate, Fire, etc.) ___Associate Degree ___Education Development (intellectual, cultural)

___Personal development ___Improve basic skills in English, Reading, or Math ___Formulate career interests, plans and goals ___Complete credit for High School Diploma ___Advance in current career; obtain promotion ___Prepare for a new career ___Undecided on goal

Heinle & Heinle © 2002 Stand Out 4 Activity Bank

Pre­Unit Worksheet 2

Name: Date:

11. WHAT IS THE HIGHEST LEVEL OF EDUCATION (BELOW COLLEGE) YOU HAVE ACHIEVED? (check one only) ____ High School Diploma ____ GED ____ Certificate of Equivalency ____ Proficiency Exam ____ Certificate of Completion ____ Foreign Diploma ____ Not H.S. grad and not attending H.S.

12. IS ENGLISH THE LANGUAGE YOU WRITE AND SPEAK MOST FREQUENTLY? ____ Yes ____ No 13. ETHNIC BACKGROUND ( check one only) ____ Alaskan Native ____ American Indian ____ Asian – Chinese ____ Asian – Japanese ____ Asian – Korean ____ Other Asian ____ Black, Non-Hispanic ____ Cambodian ____ Filipino ____ Hispanic – Central American

____ Hispanic – Mexican, Mexican-American, Chicano ____ Hispanic – South American ____ Other Hispanic ____ Laotian ____ Pacific Islander ____ Vietnamese ____ White, Non-Hispanic ____ Other ____ Decline to state

14. DO YOU WANT INFORMATION REGARDING THE FOLLOWING SERVICES? ( check each service desired) ____ Physical Disabilities ____ Child Care ____ Communication Disabilities ____ Financial Aid ____ Finding Employment ____ Learning Disabilities ____ Tutoring ____ Veterans Benefits I certify that the statements made by me are true and complete to the best of my knowledge. ____________________________________ Signature

____________________________________ Date

 

Heinle & Heinle © 2002 Stand Out 4 Activity Bank