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SOUTHWESTERN OREGON COMMUNITY COLLEGE

High School Student Record and RegistrationPrerequisite Waiver / Overload Form

Release of information: Permission is granted for information to be shared between the high school, SOCC, and other support services.

___________________________________________________ _____________________________________________

Student signature Date Advisor Signature Date

Your registration will create a financial obligation to Southwestern Oregon Community College in which you are responsible for payment of

all charges. In the event of default, the student will pay all attorneys fees, collection costs, and any other charges necessary for the collection

of any monies owed Southwestern Oregon Community College. Payment is due at time of registration.

Student ID or

Social Security #

Providing your social security number is voluntary. For tax credit eligibility determination, however, your social security numbe

is required and will be reported to the Internal Revenue Service. If you provide your social security number, the College will us

your social security number for reporting, research, keeping records, extending credit, and collecting debt. Your social securit

number will not be given to the general public. If you choose not to provide your social security number, you will not be denieany rights as a student. Please read the statement in your class schedule.

Student First Stop Center1988 Newmark AveCoos Bay, OR 97420

(541)888-7352(800) 962-2838, ext.7352

Year: Term: Summer Fall Winter Spring

www.socc.edu

Markone reason you are here this term:

__Take classes to transfer to 4 year college

__Learn skills to get a job

__Improve job skills

__Explore career or educational options

__Takes class for a HS diploma or GED__Improve writing, reading, and/or math skills

__Learn English

__Personal interest/enrichment

__Other________________________________

While at Southwestern do you plan to?

(Mark all that apply)

__Earn a certificate or 2-year degree

__Earn a HS Diploma or GED

__Take classes, then transfer to a 2 year college

__ Take classes, then transfer to a 4-year college

__Undecided

Total

Last name: First: Middle:

Other last names Birth date

Address: City: State, Zip

Phone ( ) - Other ( ) - Email:

@

Emergency contact ( ) Text Msg Email:

@

Are you a previous Southwestern student? Yes No (complete other side)

Synonym / TLN Audit

X

Course & Section # Instructors

Signature for

Prerequisite waiver

Credits

Office Use only: DC_______ TT________ XXOE: XO______ XS_______ HS_________________ Underage approved ________

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Gender: Male Female

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race: (This information is voluntary) (Circle One)

Black Hispanic Native Hawaiian/Pacific Islander

Asian White American Indian/Alaskan Other

New students: complete this side if you have not previously applied for admission.

Returning students: only complete the front side unless information has changed.

It is the policy of Southwestern Oregon Community College Board of Education that there will be no discrimination or harassment on the

grounds of race, color, gender, marital status, sexual orientation, religion, national origin, age, political affiliation, parental status, veteranstatus or disability in any educational programs, activities or employment. Persons having questions about equal opportunity and nondis-

crimination should contact the Vice President of Administrative Services in Tioga 512. Phone 541-888-7206 or TDD 541-888-7368. All

other issues, concerns, and complaints should also be directed to the Vice President of Administrative Services for referral to the appro-

priate administrator.

Are you a United States citizen? Yes No

If no are you a resident alien? Yes NoRegistration Alien #:

Country:

If no are you here on a VISA? Yes No

Have you attended college before? Yes No

Have you lived in Oregon for the last 90 days?

Yes No

If no, list previous address:_________________________________________________

_________________________________________________

Would you like information about special services forstudents with disabilities? Yes No

Are you a veteran? Yes No

Rev 04/28/08

Important dates to remember:

*Last date for a refund- end of the second week

*Financial aid students last day to add or drop- end of the second week

*Last date to audit without instructor consent- end of the 6th

week

*Last date to drop- Wednesday before finals week

High school you are attending?_______________________

_________________________________________________

Are you currently home schooled? _____________________

Year you will graduate from high school:_______________