Personal Information (Checklist item 3 of 8)

Required Fields

Birth Date:
Month None Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Day None 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
Personal Email:
Verify Personal Email:

Optional Fields

Phone Number (to receive text messages):
Social Security Number:

Gender: Male Female No Response

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race (select one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Are you a Veteran? None Yes No
Citizenship: None U.S. Citizen or U.S. National U.S. Dual Citizen U.S. Permanent Resident U.S. Refugee or Asylee Other (Non-U.S.)
If you are a non-U.S. citizen, please enter your visa type. If you are a non-U.S. citizen in the U.S. on any Visa, please contact COCC for admissions information.

COCC is not authorized to admit international students and is unable to accept the following VISA types: F1, J1 and M1. Other students are encouraged to contact an immigration official to ensure that registration at COCC does not conflict with their immigration status.

SOCIAL SECURITY NUMBER: Once your initial Application for Admission is processed, you will be assigned a COCC ID number. Use this number to register for classes and other college related business. Providing your social security number (SSN) is voluntary. If you provide it, the College will use your SSN for keeping records, research and reporting, extending credit, processing debts, and allowing students access to the COCC/OSU library systems. The College will not use your number to make any decision directly affecting you or any other person. Your SSN will not be given to the general public. If you choose not to provide your SSN you will not be denied any rights as a student. Please read the consent for information contained in the catalog, which describes how your number will be used. Providing your SSN means that you consent to use of the number in the manner described.

NON-DISCRIMINATION POLICY: It is the policy of the Central Oregon Community College Board of Directors that there will be no discrimination or harassment on the basis of age, disability, gender, marital status, national origin, color, race, religion, sexual orientation or veteran status in any educational programs, activities or employment. Persons having questions about equal opportunity and nondiscrimination should contact the Equal Employment Officer, c/o COCC's Human Resources office, (541) 383-7216. Faculty, staff and students are protected from discrimination and harassment under Title VII of the Civil Rights Act of 1964 and Title IX of the Education Amendments of 1972. Persons who, because of a physical or learning disability, need special accommodation should contact ADA Coordinator Joe Viola, (541) 383-7776, in advance of their need for accommodation. Further inquiries may be directed to the Affirmative Action Officer, c/o COCC's Human Resources office, (541) 383-7216.