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Heartland Community College
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STUDENT INFORMATIONName (Last)
 
(First)
 
InitHCC ID#EmailPrevious/Alternate Last Name(s)Preferred NameSocial Security NumberGenderPhone (home)Phone (work)Birthdate
...
AgeMarital Status
 
Address
 
Apartment
 
CityStateZip
 
CountyOther CountyIs English your first language?
 Native Language
 
Native CountryVisa StatusOther Visa StatusWhat is your primary racial group?
 
Select all that apply:Select all that apply:
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CLASS PREFERENCESWhich class schedule would you prefer? 
 Which would you prefer?
  
EMERGENCY CONTACT INFORMATIONName:
 
 Relationship:
 
Relationship Other
 
Phone Number:
 
  EDUCATIONAL BACKGROUND INFORMATIONSchool Type US Based?
 
 Highest Grade Completed:Last U.S. High School Attended:Last Enrolled: MM/YY US High School Equivalency?
 
 US Diploma?
 
 Have you taken and passed the Constitution Test?Have you taken the GED test after 2014?
Please check any sections of the GED that you have passed:
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OTHER INFORMATIONEmployment Status
 
Employer Name
 
 Hours worked per week
 
Referral from WIOA Core Partner or One Stop
If Yes, Name of referring partner/One Stop
 
 Public Assistance:Public Assistance:
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* I understand that by marking the Disability box I give my permission for the ADA Coordinator to contact DSS and my instructor.Disability StatusDo you need Transportation Assistance?
Do you need Childcare?
  How did you hear about this programOther: What career path Interests you?  Please identify any barriers to employment that you face, regardless of employment status. Please select all that apply:Please identify any barriers to employment that you face, regardless of employment status. Please select all that apply:
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Please check all that apply:
 
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By typing my name, I verify that all information provided is accurate and I can provide documentation if necessary.Signature:
 
 Date:
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Authorization of Release of InformationName (Last): (First) :Middle:PHOTO RELEASE
HSE TEST RELEASEI hereby agree to release my HSE (GED, HiSet, TASC) scores to the Adult Education department at Heartland Community College. These scores will be kept strictly confidential.
ACADEMIC RECORD RELEASE
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I release the above information to the following:
Name (other than self)
Mc Lean County Court Services
Logan County Court Services
Livingston County Court Services
Student Access and Accommodations Services (SAAS) at Heartland Community College
OtherName:Agency:Phone:  
 Signature:Date:
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