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Student Information
Legal Name*
First Last
Preferred Name*
First Last
Sex*
- Male
- Female
Date of Birth*
MM
DD
YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Marital Status*
- Single
- Married
- Divorced
- Widow/Widower
- Separated
Birth Last Name*
Citizenship*
- USA
Ethnic Background*
- American Indian / Alaskan Native
- Asian / Pacific Islander
- Black / Non-Hispanic
- White / Non-Hispanic
- Hispanic
- Other
SSN
Preferred Phone Number*
- Select All
- Cell
- Home
- Work
Cell Phone*
Text Message Communication*
- Yes
- No
Home Phone*
Work Phone*
Email*
Have you ever been arrested for, charged with, or convicted of criminal conduct, a misdemeanor or a felony**
*may effect licensure/credentialing
- No
- Yes
Are you seeking financial assistance through any State or Federal Agency?*
- Workforce Oklahoma
- Vocational Rehab
- VA
- DHS
- Native American Tribe
- Other
- I am not seeking assistance through any agency

Educational Background
Have you ever been enrolled at Community Care, Clary Sage or Oklahoma Technical College?*
- Yes
- No
Education Level
Graduation Date / Date GED Recieved*
Fill month and day to the best of your knowledge - Year is important
MM
DD
YYYY
List All other Colleges, Vocational or Technical Schools*
Include whether or not you graduated - Write none if this is not applicable

Getting to know You
What Career are you interested in Today?*
How soon would you like to start classes?*
- ASAP
- 1-2 Months
- 2-6 Months
- 6+ Months
What led you to choose this field?*
What three questions are you hoping to get answered by your admissions representative?*
Where do you see yourself in 3 years?*
What goals will your education help you achieve?*
Our goal is to turn every student into a graduate! What challenges might stand in your way of attending class and/or becoming a successful graduate and what can you do to overcome these challenges? (Ex: Transportation, Bus fare, Family, Finances, Educational challenges)*
Emergency Contacts
2 Emergency Contacts are required
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*
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
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Student Information