Aravaipa
Maricopa
San Tan
Signal Peak
Superstition
Florence
Coolidge
Saddlebrooke
Casa Grande
Casa Grande Corporate
Registration/Admission
Student Information Form
Semester of Enrollment: Year 20______
Fall
Spring
Summer
Student ID Number/
Social Security Number
1
Legal Name: Last:_____________________________________________
First:______________________________________________
Middle Initial:_________
Previous Name (maiden):_________________________________________________________________________________________
2
Mailing Address: Street/P.O. Box:___________________________________________________________________________________ Apt.:___________________
City:_________________________________________________________________
3
Telephone: Home:(_________)________________________
4
Emergency Contact:
5
State:___________________________
Cell:(_________)________________________
Zip:__________________________
Business:(_________)________________________
Name:_________________________________________ Relationship:_________________________ Phone: (_________) ________________
Please indicate whether you plan to pursue a degree or certificate: ( * please select appropriate code from list located on the back)
Associate of Arts Degree (AA) _____________________
Associate of Arts Degree – Elementary Education (AAEE)
Associate of Science Degree (AS)
Associate of Applied Science Degree (AAS) _______________________*
Associate of Business Degree (ABUS)
Certificate __________________________*
Associate of General Studies Degree (AGS)
Please note: All students receiving Financial Aid must declare a program of study and provide Official Transcripts from previous institutions attended.
6 Reason for Enrollment:
7
Male
Job Advancement
Personal Interest
Improve Reading/Writing/Math Skills
Transfer to a Four-Year School
Other
8 Date of Birth:________/________/________
Month
Day
Year
Female
9 Race/Ethnic Background CAC is a Hispanic Serving Institution. As such, CAC receives extra federal funding to support its students. In order to qualify for the funding we must maintain at least 25% of our student body as
Hispanic /Latino/Chicano. Therefore, it is VERY IMPORTANT that if you identify with one of these groups you mark the appropriate box. This information will NOT be used in ANY other way.
Are you of Latino/Hispanic ethnicity?
YES, please specify:
Mexican
Cuban
Chicano
Central American
South American
Spanish
-OR-
Select one type that best describes your status:
Minor/Under 18
Dual Enrollment
Transfer
New/First Time
NO, if not of Latino/Hispanic ethnicity, please check all that
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
White, Non-Hispanic
Black/African American
10 Student type:
11 Did you graduate from High School?
Yes_______/_______
Re-entry, returning after one or more semesters
No, GED_______/_______
12 Name of High School:___________________________________________________________________
No, Currently Enrolled
Continuing
Inmate
Other
City_________________________________
State__________
13 Have you attended other colleges?
Yes
No
If yes, list all colleges attended: (1)__________________________ (2)__________________________(3)__________________________(4)__________________________
Failure to disclose previous college(s) is a violation of the Student Code of Conduct and is grounds for denial of admission or immediate suspension if enrolled. It is the responsibility of the student to provide Official Transcripts from
all institutions indicated above for prior credit evaluation.
14 Did you earn a degree?
Yes
No
If yes, degree earned: __________________________________
15 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. 15-1802.01. Failure to
answer questions may result in being classified as out-of-state for tuition and fees purposes. The responsibility of registering under the proper residency classification is placed upon the student. Any
student who falsified his/her residency may be subject to dismissal from the college and/or criminal action. Refer to the college catalog for residency guidelines.
United States Citizen
Legal Immigrant/Permanent Resident: Date of Issue ____/______
Lawful Refugee/Asylee: Date of Issue _____/_____
Country of Origin ________________
Legal Nonimmigrant: Specify Immigration Classification ________ and Date of Expiration _______/_______ and Alien Registration Number/I-94 Number ____________
Do Not Qualify for any of the above
Yes
No
If yes, what date did your present stay begin in Arizona?: (if born in Arizona, state birth year) _______/_______
16 Are you a legal Arizona resident?
If less than a year, in what state did you reside? _____________________________________
17 Are you seeking admissions under the Western Undergraduate Exchange Program?
CRN
Course Number
Section
Yes – which state do you currently reside?____________________
Course Title
Credits
Days
I certify that the information given is complete to the best of my knowledge. I understand that submission of false information is grounds for denial of admission or immediate
suspension if enrolled. If accepted as a student of Central Arizona College, I agree to abide by the rules and regulations of the college regarding conduct and other obligations.
Student Signature: ____________________________________________________ Date: ___________________________________
No
Time
Advisor:
_________________
Max Hour Approval:
__________________
Associate of Arts (AA)
1421
0007
1377
1375
1376
0001
1371
Administration of Justice Studies
Agriculture
Athletic Studies
Athletic Training Educ. Program
Fine Arts
Liberal Studies
Recreation/Tourism Mgmnt.
Associate of Arts –
Elementary Education (AAEE)
1418 Elementary Education
Associate of Business (AB)
0001 Liberal Studies
Associate of Science (AS)
0007
1380
1401
0017
1201
0001
Agriculture
Biotechnology
Chemistry
Community Public Health
Geology and Planetary Science
Liberal Studies
Associate of General Studies (AGS)
0002 General Studies
1330 Pre-Nursing
Associate of Applied Science
(AAS)
1110 Accounting
1421 Administration of Justice
1500 Agriculture, General
0021 Artist & Venue Mgt
1120 Business
1130 Computer Programming
1495 Corrections
1229 Culinary Arts
0008 Diagnostic Med. Sonography
1517 Diesel/Heavy Equip. Tech.
1310 Dietetic Technician
1303 ECE Family Child Care
1305 ECE Infant/Toddler
1306 ECE Management
1302 ECE Preschool
1362 Fire Science Technology
0031 Geographic Information Syst
1334 Graphic Design
1367 Health Information Tech.
1514 Heavy Equipment Operator
1140 Hotel/Restaurant Mgmnt.
1535 John Deere Construction
1541 John Deere TECH
1149 Live Audio & Lighting
1499 Manufacturing Engineering
1363 Massage Therapy
1357 Medical Assistant
1131 Microcomputer Bus. App.
1498 Nanofabrication Technology
0027 Network Systems Admin
1333 Nursing (for accepted applicants
1339
0019
only. All others, use Pre-Nursing)
Paramedicine
Popular Music Perform.
Associate of Applied Science (AAS)
(cont.)
0013
0020
1370
Radiologic Technology
Recording Engineering
Sports Management
Certificate Programs
1110
1421
1496
1502
1500
1127
0021
0029
1542
0022
1120
1324
1309
1518
1129
1130
1378
1543
1174
1175
1307
1517
1323
1304
1305
1306
1302
Accounting
Administration of Justice
Advanced Corrections
Agriculture Business
Agriculture, General
Application Dev/Web Design
Artist & Venue Mgt
Baking and Pastry
Basic EMT
Biofuels Technician
Business
Clinical Lab Assistant
Community Nutrition Worker
Computer Aided Design
Computer Appl. for Bus. Users
Computer Programming
Coding and Reimbursement
Critical Care for Paramedics
Culinary Arts I
Culinary Arts II
Diabetes Care and Education
Diesel/Heavy Equip. Tech.
Dietary Manager Training Prog.
ECE Family Child Care
ECE Infant/Toddler
ECE Management
ECE Preschool
Certificate Programs (cont.)
0016
1503
1504
0030
1320
0028
1364
1540
1514
1140
1505
1149
1151
1527
1363
1113
1131
1125
1325
1536
1365
1114
0019
1331
0020
1373
1374
1525
1115
Equine Mgt Training
Farm Business Management
Field Programmable Gate Array
Firefighter Operations
Food Service Management
GIS Drafting and Mapping
Group Fitness Instructor
HE Mechanics App. Prog./AGC
Heavy Equipment Operator
Hotel/Restaurant Mgt
LabVIEW Programming
Live Audio & Lighting
Management
Manufacturing Electronics
Massage Therapy
Medical Assistant
Micro. Bus. App. Specialist
Network Administration
Nutrition and Health Promotion
Operator App. Program/AGC
Personal Trainer
Pharmacy Technician
Popular Music Perform.
Practical Nursing
Recording Engineering
Recreation Management
Sports Information
Welding
Wildland Firefighter I
Step 1: Admission: Fill out the entire Student Information Form and submit by mail, or at www.centralaz.edu. A student ID card is
required for all transactions at Central Arizona College. There is no charge for the first ID; there is a replacement fee of $10.
Step 2: Orientation: The College requires completion of assessment (placement testing) in the areas of writing, reading, and
mathematics prior to meeting with an advisor and registering. Assessment is used to place students in English, math, and other
courses based on test scores which have identified minimum skill levels. Orientation is strongly recommended for new students in
order to become acquainted with the nature, purpose, services, activities and resources of the College. Call the campus nearest
you to register for an orientation.
Step 3: Advisement: All students pursuing a degree or certificate or enrolling in a course with a prerequisite, must meet with an advisor
prior to registration. If you have attended a prior college, bring copies of your transcripts to your advising session.
Step 4: Registration: Students must complete an official registration form in order to be officially enrolled in classes. Registration dates
are published each year in the Academic Calendar. Learning starts day one, students are only permitted to enroll in a class that
has not already met. Contact the Registration Office for additional information. Changes in a student’s schedule, such as
dropping or adding classes, may be accomplished on-line at www.centralaz.edu or in person. Phone requests regarding
registration are not permitted.
Step 5: On-Campus Housing: (available only at the Signal Peak Campus.) Complete a housing application, pay the $100 deposit and
provide proof of immunizations to the Residence Life Office or at 520-494-5470. Students interested in on-campus housing must
apply early for a guaranteed assignment.
Step 6: Fee Payment: Payment of all tuition and fees is required at the time of registration. Students will be withdrawn from courses
for non-payment. Fee payment may be made in person, by mail, or by eCheck and credit card online at www.centralaz.edu. It is
the responsibility of the student to be aware of the tuition refund/withdrawal policy.
All 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 College Catalog.
*
Students will be assigned a unique student identification number. Students should be aware that a correct Social Security number
must be on file for reporting information pertaining to potential tax credits and must be used by applicants for federal and state
aid. Failure to provide a correct social security number may preclude the determination of eligibility for financial aid and tax
credits for tuition.
**
Voluntary information is used to comply with Federal reporting and has no effect on admission to the college. This information
will not be used for any discriminatory purposes.
Revised: 6/2013
www.centralaz.edu