DART Student Demographic Form The information provided here

DART Student Demographic Form
The information provided here will be kept confidential. All data are reported in
aggregate form; individual students are not identifiable in reports to outside
Colleges and universities are asked by many, including the federal government,
accrediting associations, college guides, newspapers, and our own
college/university communities, to provide information and describe the
racial/ethnic backgrounds of our students and employees. In order to respond to
these requests, we ask you to answer the following questions:
1. Name: _______________________________ _______________________________ _____
(First, Middle, Last)
2. Permanent Address:
City: __________________________________, State: ___________. Zip Code: __________________
Home Phone#: _________________________________
Cell Phone#: ____________________________________
School E‐mail: ______________________________________________________
Permanent E‐mail: _________________________________________________
4. Gender:
☐ Male
5. Are you Hispanic/Latino?
☐ Female
☐ Yes
☐ No
If Hispanic/Latino, is your background (select one):
☐ Central American
☐ Dominican ☐ Mexican
☐ South American ☐ Other Hispanic/Latino
☐ Puerto Rican
6. Is your race (select one or more):
☐ American Indian or Alaskan Native ☐ Asian ☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander ☐ White
7. Military status (if applicable):
☐ Active Military Duty
☐ Dependent of Active Duty
☐ National Guard or Active Reserve
☐ Veteran
8. Have you ever been arrested or been subject to any disciplinary action?
☐ Yes
☐ No
If yes, please explain:
Student: Please email PDF file to Dr. Book at: booksw@musc.edu