Admissions

- PRINT OUT a blank form
- FILL IT OUT
- RETURN  IT TO:

Lansing Community College
1121 - Enrollment Services Office
PO Box 40010, Lansing, MI
48901-7210
Phone: (517) 483-1200
Fax: (517) 483-9668

Social Security Number:

SEMESTER YOU PLAN TO BEGIN:
(Check one)

Jan - May

Jun-July

Aug-Dec

Spring 20____

Summer 20____

Fall 20____

___________________________________      ___________________________________
Last Name                                                                    First Name 

___________________________________  ___________________________________
Middle Name                                                           Former Last Name

 ______________________________________________________________
 Address (include apartment number, if any)

___________________________________
City

_____     ___________________________
State       ZIP CODE

___________________________________
(Area Code) HOME TELEPHONE NUMBER

__________________________________
(Area Code) ALTERNATE TELEPHONE NUMBER

___________________________________
E-mail
 

GENDER
Male
Female

DATE OF BIRTH

____/____/______
Month  Day  Year

ETHNIC BACKGROUND

American Indian or Alaskan Native (1)
Asian or Pacific Islander (2)
Black - Non-Hispanic (3)

Hispanic and Chicano (4)
White - Non-Hispanic (5)
Other (6)

ARE YOU MULTIRACIAL?
Yes
No
 

CITIZENSHIP
U.S. citizen (01)
Political asylee (Attach copy of I-94 card) (91)
Refugee (Attach copy of I-94 card) (92)

Resident Alien (Attach copy of RA card) (93)
Temporary protected status (95)
 

The information requested in this box is VOLUNTARY and will be held in confidence. This information is needed for summary reports and will not be used as a factor in the admissions process. Lansing Community College complies with all federal and state requirements, which include collecting this information. Failure to respond will not result in any negative action against you.

CURRICULAR CODE
׀__׀__׀__׀__׀

MAJOR AREA OF STUDY

STUDENT TYPE (Check one)

New Student (first time attending LCC) (N)

Continuing student (C)

Guest Student (currently enrolled at another college) (G)

Transfer (T)

SCHOOL DISTRICT IN WHICH YOU RESIDE

LENGTH OF
TIME IN SCHOOL DISTRICT

YEARS   MONTHS

׀__׀__׀__׀__׀
R   M   U    I

EDUCATIONAL GOAL
(Choose one)

Associate Degree (A)
Certificate of Achievement (CA)
Certificate of Completion (CC)
Job Advancement (JA)
Maintain Licensure (ML)

Other (OT)
Personal Interest (PI)
Transfer to two-year school (T2)
Transfer to four-year school (T4)

NAME OF HIGH
SCHOOL ATTENDED

City: ___________________________ State:_________________
 

I graduated or will graduate on

My high school grade point average (GPA) is: (Check one)

4.0 (A)

3.0 (B)

2.0 (C)

1.0 (D)

0.0 (E)

How many hours per week do you plan to work your first semester? (Check one)

Not working (A)
10 hours/ week or less (B)

11 to 20 hours/ week (C)
21 to 30 hours/week (D)

31 to 40 hours /week (E)
More than 40 hours/ week (F)

My financial situation regarding college is as follows: (Check one)

I will have enough money (A)

I will need financial assistance (B)

I don't know yet (C)

Did either of your parents complete: (Check highest)

High school (A)
Two-year College (B)

Four-year College (C)
Graduate Degree (D)

Have you been convicted of a felony in the last five years?

Yes

No

The college does not have a policy of excluding any person having felony convictions but will exercise judgment as to whether the violation and date on which it occurred present a threat  to the safety and security of the college. Please feel free to contact the Director of Student Relations, (517) 483-1163; regarding this question.

The above information is correct and complete to the best of my knowledge:

Signature: ______________________________________  Date Submitted:_______________________