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Student Information

Legal Name*

First Last

Preferred Name*

First Last

Marital Status*

Single:

Never Married
Previously Married

Maiden Name

Sex*

Male
Female

Date of Birth*

Are you over 18 y/o?

Yes (Over 18)
No (Under 18)

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

OK to text?*

Yes
No

Hidden

Home Phone

Hidden

Work Phone

Hidden

Preferred Phone Number

Select All
Cell
Home
Work

Email*

Best Way to Contact

Call
Text
Email
Facebook Messenger

Citizenship*

USA

SSN

Ethnic Background

Tribe

Have you ever been arrested for, charged with, or convicted of criminal conduct, a misdemeanor or a felony**

*may effect licensure/credentialing

None
Misdemeanor
Felony

Are you seeking financial assistance through any State or Federal Agency?*

Current Employer Information

Have you ever been employed?*

Yes
No

Are You Currently Employed?*

Yes
No

Employer Name*

Employer Phone Number*

Position*

Start Date*

End Date*

Educational Background

Education Level*

Name Of High School*

Graduation Date / Date GED Recieved*

Fill month and day to the best of your knowledge - Year is important

List All other Colleges, Vocational or Technical Schools*

Include whether or not you graduated - Write none if this is not applicable

Have you ever been enrolled at Community Care, Clary Sage or Oklahoma Technical College?*

Yes
No

Getting to know You

1) What career are you interested in today?*

Interested in an Associates of Occupational Science Degree?

Yes
No

2) How soon would you like to start classes?*

ASAP
1-2 Months
2-6 Months
6+ Months

3) What three questions are you hoping to get answered by your admissions representative?*

4) Where have you seen us?*

Click all that apply.

If referred, who can we thank?

Which radio station?

Thank you for expressing interest in our College! In an effort to get to know you better please answer the following questions. A minimum of 3 complete sentences on EACH of the following 4 questions is required in order to be considered for enrollment.

1) Where do you see yourself in 3 years? What goals will your education at this college help you achieve?*

2) What led you to choose this field and this college?*

3) Tell us about your current situation.*

4) Our goal is to turn every student into a graduate! What challenges might stand in your way of becoming a successful graduate? What can you do to overcome these challenges in order to be successful? (Ex: Transportation, Bus fare, Family, Finances, Educational challenges)*

Emergency Contacts

2 Emergency Contacts are required. Almost there, one more page!

Emergency Contact 1*

First Last

Relation

Phone*

Email*

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact 2*

First Last

Relation*

Phone*

Email*

Address

Street Address Address Line 2 City State ZIP Code

I certify the information is true to the best of my knowledge and belief and I understand that I subject myself to disciplinary action in the event that the application facts are found to be falsified

Signature

Signature of Parent or Guardian

Student Information

Current Employer Information

Educational Background

Getting to know You

Emergency Contacts

I certify the information is true to the best of my knowledge and belief and I understand that I subject myself to disciplinary action in the event that the application facts are found to be falsified

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