Name Information

Legal First Name

Legal Middle Name

Legal Last Name

Suffix

Contact Information

Zip Code

Address (Number/Street)

Address, continued (as needed)

City

State

County of residence

Country

Primary Phone Number

Email Address

Confirm Email Address

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone Number

Secondary Education

Degree Earned

Graduation Year

GED Completion Year

High School State

Select Institution from List

School Not in List

Select GED Institution from List

Name of School (not available in dropdown list above)

High School State

High School City/Town

Personal Information

Birth Date (mm/dd/yyyy)

Marital Status

Sex

Maiden Name

Citizen Of

SSN

English is a second language?

Please record native language

Are you Hispanic or Latino/Latina?

Race

Race (Choose one or more)

Are you a veteran?

Branch of Military Service

Disability

Have you been convicted of a felony?

Check any organizations that you have contacted about funding opportunities for this program

Employment

Current Employment Status

Estimated Family WEEKLY Income

Number in Family Unit

Non-Discrimination Statement

Richland Community College does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs. The following person(s) has been designated to handle inquiries regarding the nondiscrimination policies:

Jennifer Reichart, Title IX Coordinator at phone 217-875-7211 EX 6776
Dr. Priscilla Palmer, 504 Coordinator at phone 217-875-7211 EX 309

For further information on notice of nondiscrimination, visit https://ocrcas.ed.gov/contact-ocr for the address and phone number of the office that serves your area, or call 1-800-421-3481.

Signature Verification

I certify that all of the information on my Registration Form is correct and complete.

Planned Starting Month

Planned year to start program