Nonpublic Home School/ Special Admission Application Form
- 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
LCC Office use only
ADMT_______________________________
Processed by
Date
ADMS_______________________________
Processed by
Date
PC to Dept.__________________________
Processed by
Date
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)
EDUCATIONAL
LEVEL (Check highest
level completed)
Less than high
school (LH)
Currently in
high school (9th and 10th) (FS)
Currently in
high school (11th and 12th) (JS)
Home school (age
14 and 15) (H1)
Home school (age
16 and 17) (H2)
GED passed
(GED)
High school
graduate (HS)
Some college
credits (CR)
Associate Degree
(AD)
Bachelor's
Degree (BD)
Master's Degree
(MD)
Doctorate/Professional
Degree (DP)
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:_______________________
After completed the Special
Application form
above, please go to the Approval Form:
Nonpublic Home School/ Special Admission Application Form
