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Ccac Registration Form: Central E-Services

This document is a registration form for the Community College of Allegheny County (CCAC). It requests basic student information such as name, address, date of birth, citizenship status, residency, veteran status, and contact information. The form also asks students to select the preferred CCAC location and provides a list of locations. Additionally, it collects optional demographic information and asks students to provide their program code and course details for registration including subject, course number, section, credits, days/times. Signatures of the student and advisor are required.

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Bradley Jonathan
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35 views1 page

Ccac Registration Form: Central E-Services

This document is a registration form for the Community College of Allegheny County (CCAC). It requests basic student information such as name, address, date of birth, citizenship status, residency, veteran status, and contact information. The form also asks students to select the preferred CCAC location and provides a list of locations. Additionally, it collects optional demographic information and asks students to provide their program code and course details for registration including subject, course number, section, credits, days/times. Signatures of the student and advisor are required.

Uploaded by

Bradley Jonathan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CCAC REGISTRATION FORM You can also register online at CCAC Central e-Services.

Check Preferred Location

e
Allegheny Boyce North South CCAC
Homewood-Brushton Center Braddock Hills Center West Hills Center Bethel Park Center CENTRAL
Washington County Center
e-Services

Student Identification Number Social Security number required, if not already submitted.

Last Name First Name Middle Initial

Street Address Apt.

City State Zip County

Home Phone Alternate Phone Email Address

Date of Birth (Month/Day/Year)


Citizenship Status (Check one) United States Citizen Resident Alien Non-Immigrant Visa holder/ International Student Non-immigrant Alien
Residency Status (Check one) Domicile shall mean a person’s true, fixed and permanent home, to which one intends to return after being absent.
In Allegheny County Out of Allegheny County with Community College Out-of-state

Are You a Military Veteran? No Yes (See below) Are You a Dependant of a Veteran? No Yes (see below)
Veteran Benefits: 30 Montgomery 1606 Reserve 35 Dependent Vietnam Veteran Disabled Veteran Chapter 33 Post-9/11 GI Bill VEAP Chapter 32 Chapter 31

Voluntary Information (Please check one in each section)


Providing the information below is optional. This voluntary information is used to comply with federal reporting and has no effect on admission to the college.
Ethnicity and Race
Hispanic/Latino/Spanish origin No Yes
Select all that apply: American/Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Other
Marital Status Sex
Married Single Male Female

My Program is with Code .

Student Signature Date


Days Time
Location Term Catalog Course No. Section Audit Course Title Credit
U M T W R F S From To

If you are registering for an Online Learning course, visit dlsupport.ccac.edu/gettingstarted.

Advisor Comments

Advisor Signature Date Student Signature Date

Registration is not complete until payment is made in full (grants, scholarships and anticipated loans; self-payment, tuition payment
plan [spring & fall only], sponsorship or any combination).
I understand that once I register I become responsible for all charges incurred, unless I drop during the designated refund periods.
I also understand that the college is extending credit to me and permitting me to register, enroll and attend classes in return for my
promise to pay the college all tuition and fees incurred as a result of my attendance and that such extension of credit constitutes an
educational loan or educational benefit that is non-dischargeable under Section 523 (a)(8) of the United States Bankruptcy Code.
The college is subject to provisions of and complies with the Family Educational Rights and Privacy Act of 1974. A statement of the college policy can be found in the student handbook and college catalog.

Revised: April 1, 2011

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