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Registration Form
CLOVER PARK TECHNICAL COLLEGE
4 5 0 0 S t e i l a c o o m B o u l e v a r d S .W . · L a k e wo o d , W A 9 8 4 9 9
PLEASE PRINT
Quarter of Registration
SUMMER
FALL
STUDENT ID NUMBER
-
SPRING
Registration Form
20_____
LAST NAME
FIRST NAME
PREVIOUS LAST NAME
-
NEW STUDENT
FORMER STUDENT
APT #
CITY
STATE
WHAT IS YOUR GOAL FOR ATTENDING CPTC?
(11) Take courses related to current/future work
(14) Explore career direction
Yes
No (if no, check type of Visa)
DISABILITY?
Yes
No
#
F
DAY
-
-
EVENING
-
-
EMERGENCY
-
-
No, I do not consent to the use of my SSN for the above stated purpose.
STREET
U. S. CITIZEN?
ITEM
SEX
TELEPHONE CONTACT NUMBERS
*
Yes, I give my consent.
STUDENT
PURPOSE
BIRTHDATE
M
I authorize this college to use my Social Security Number to obtain employment and wage information held by the Employment Security
Department for the purposes of state and federal educational reporting, evaluation and research.
CURRENT
ADDRESS
MI
-
SOCIAL SECURITY NUMB ER
-
WINTER
E-MAIL ADDRESS
ZIP
(13) High school diploma or GED
(15) Personal enrichment
Resident Alien/Immigrant (IM)
Visitor Pleasure (B2)
Student (M1)
Other (ZZ)
(12) Transfer to a 4-year college
(90) Other
Refugee (RF)
Visitor Business (B1)
Do you have physical, sensory or mental impairment that substantially limits one or more of the major life functions such as seeing, hearing, speaking, walking,
breathing, working with your hands, learning, caring for self or working? To request accommodations, contact Advising/Counseling at (253) 589-5767.
COURSE ID
TITLE
START DATE
Effective Fall 2014, a late fee of $30.00 per class will be assessed for students registering after the 5 th day of classes.
NEW STUDENTS:
You must complete all the questions on the reverse
side of this page.
STUDENT SIGNATURE
DATE
By signing this document, student agrees to be bound by CPTC policies and procedures as set forth in the Student Handbook and online.
*To comply with federal laws, we are required to ask for your Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN). We will use your SSN/ITIN to report American Opportunity tax credit, to administer state/federal financial aid, to
verify enrollment, degree and academic transcript records, and to conduct institutional research. If you do not submit your SSN/ITIN, you will not be denied access to the college; however, you may be subject to civil penalties (refer to Internal Revenue Service
Treasury Regulation 1.6050S-1(e) (4) for more information).Pursuant to state law (RCW 28B.10.042) and federal law (Family Educational Rights and Privacy Act), the college will protect your SSN from unauthorized use and/or disclosure.
NON-DISCRIMINATION POLICY:
Clover Park Technical College does not discriminate on the basis of race, color, national origin, sex, disability, sexual orientation/gender identity, veterans status, religion, or age in its programs and activities. The following office has
been designated to handle inquiries regarding the non-discrimination policies: Chief Human Resources and Legal Affairs Officer, 4500 Steilacoom Blvd SW, Lakewood, WA 98499. Telephone (253)589-5533.
The College’s total liability for claims arising from a contractual relationship with the student in any way related to classes or programs shall be limited to the tuition and expenses paid by the student to the College for those classes or programs.
In no event shall the college be liable for any special, indirect, incidental, or consequential damages, including but not limited to, loss of earnings or profits.
LIMIT OF LIABILITY:
Rev. 05/29/14 cmowry
LAST HIGH SCHOOL ATTENDED
EDUCATIONAL
BACKGROUND
CITY
LAST COLLEGE ATTENDED
LIMITED ENGLISH
PROFICIENCY
(2) YES
CITY
STATE
STATE
LAST YEAR ATTENDED
GRADUATED?
LAST YEAR ATTENDED
GRADUATED?
YES
YES
NO
NO
An individual not born in the United States or whose native language is a language other than English, and who by reason thereof, has sufficient difficulty
speaking, reading, writing, understanding the English language.
Student information will be protected by the Educational Rights & Privacy Act of 1974. Information is requested to comply with state and federal requirements.
PLEASE MARK THE NUMBER THAT BEST APPLIES TO YOU
Which race do you consider yourself to be?
(Please mark up to two choices)
White (800)
African/American (872)
American Indian (597)
Alaska Native (015)
Native Hawaiian (653)
Other Pacific Islander (681)
Vietnamese (619)
Filipino (608)
Chinese (605)
Korean (612)
Japanese (611)
Other Asian (621)
Other Race (specify) ___________________________
Are you Spanish/Hispanic/Latino ethnicity?
No (999)
Yes, Mexican, Mexican American, Chicano (722)
Yes, Cuban (709)
Yes, Puerto Rican (727)
Yes, Other Spanish/Hispanic/Latino (please specify)
What is your family status?
(11) A single parent with children or other dependents in your
care
(12) A couple with children or other dependents in your care
(13) Without children or other dependents in your care
(90) Other __________________________________
How long do you plan to attend Clover Park Technical College?
(11)
(12)
(13)
(14)
(15)
(16)
(90)
One quarter
Two quarters
One year
Up to two years
Complete a degree
Don’t know
Other __________________________________
The college appreciates your response to the following
questions. All information will be maintained with the strictest
confidentiality.
What is your sexual orientation?
Bisexual (72)
Gay (99)
Lesbian (21)
Queer (28)
What is your current work status while attending CPTC?
(11) Full time homemaker
(12) Full time employment (including self-employed
and military)
(13) Part time off campus
(14) Part time on campus
(15) Not employed, but seeking employment
(16) Not employed, not seeking employment
(90) Other __________________________________
What is your prior level of education at entry to CPTC?
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(90)
Less than high school graduate
GED
High school graduate
Some post high school, but no degree/certificate
Certificate
Associate degree
Bachelor’s degree or above
Other __________________________________
Straight/heterosexual (23)
Other (01)
Prefer not to answer (57)
What is your gender identity?
Feminine (22)
Masculine (77)
Androgynous (52)
Gender neutral (35)
Transgender (27)
Other (01)
Prefer not to answer (57)
FOR OFFICE USE ONLY
MAIL TO:
Have you served in the U.S. Armed Forces? (V$)
Veterans and/or their dependents may qualify for
educational benefits. Please call the VA at 1888-442-4551 or go to www.gibill.va.gov for more
information.
Rev. 05/29/14 cmowry
Enrollment Services
Clover Park Technical College
4500 Steilacoom Boulevard S.W.
Lakewood, WA 98499
Phone:
FAX:
(253) 589-5666
(253) 589-5852
EHS
HS Code __________
Running Start
Grade
HS Advisor ____________________________________
—————————————————
COMPASS SCORES
W_____________
R___________
A______________
WFT___________________________
PA____________
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