CTE Student Services Questionnaire

CTE STUDENT SERVICES QUESTIONNAIRE

MISSISSIPPI DELTA COMMUNITY COLLEGE

Mississippi Delta Community College would like to provide services necessary to promote success for you in your program.

All information is confidential and is used for statistical purposes only.

Personal Data

Date:*

Name*

First Name

Middle Name (optional)

Last Name

Mailing Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number:*

Date of Birth:*

Age:*

Gender:*

Male Female

ID: D00000000*

Race:*

Black/African American White Asian HIspanic Other

Marital Status:*

Single Married Divorced Separated Widowed

Out of Workforce:

Little or no work outside home

Are you currently registered with disability services at MDCC?*

Yes No

Are you a single mother or father (including those currenlty pregnant)?*

Yes No

Are you currently homeless outside of university housing?*

Yes No

Are you currently in, or have aged out of, the foster care system?*

Yes No

Are either one of your parents active members of the US military?*

Yes No

Are you currently on active duty in the US military?*

Yes No

Number of Children:*

Ages:*

Program of Study/ Advisors:*

Are you pursuing:*

1 YR Certificate 2 YR Certificate AAS Degree

Education

Are you currently?*

Freshman Sophmore

Did you receive a High School Diploma?*

Yes No

Did you receive a Certificate of Attendance?*

Yes No

Certificate of Attendance Year*

Did you attend a Vocational or Technical Education in High School?*

Yes No

Vocational / Technical Program:*

Did you obtain a GED Certificate?*

Yes No

GED Year*

Is English your native language?*

Yes No

If no, list your native language.

Tuition Assistance:*

Pell Grant /FASFA Self-Pay Academic Scholarship

Other:

MDCC STUDENT / PATRON USE AGREEMENT

I hereby agree to the following conditions with regard to use of the college network resources. Specifically, I will not:

I understand my responsibility with respect to ensuring appropriate security, confidentiality, and use of the college network. I also understand that the college is not responsible for any consequences or legal actions that may result because of my misuse of the college network resources. I have read and do understand the above conditions. I realize that failure to comply with any of the above conditions can result in disciplinary action against me as described in the college's Student Handbook.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date/Time*

Mississippi Delta Community College does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: The Associate VP for Institutional Effectiveness, Boggs-Scroggins Student Services Center, P.O. Box 668, Moorhead, MS 38761, 662-246-6558.