ON-LINE APPLICATION

Please note this is not a secure connection.
If you prefer we suggest using the mail-in option .

NAME
	Last Name
	First Name
	Middle Name(s)
	Maiden Name
	Preferred Name
.
ADDRESS
	Mailing Address
	City
	County
	State
	Zip
	Country
	Telephone Number
	Mobile Phone
	Email Address
	Confirm Email Address
.
DEMOGRAPHICS
	Social Security Number
	Date of Birth
	Sex
	Marital Status
	Spouse's Name
	Number of Children
	Ethnic Group
	Citizenship
.
ADMISSION REQUIREMENTS
	When do you desire admission?
	Classification Sought
	Major
	Housing Plans at CRC (note: rules for living off campus)
.
PREVIOUS ACADEMIC HISTORY
	Last College Attended (if applicable)
	Last High School Attended
	Mailing Address
	City
	State
	Zip
	Country
	Counselor/Principal
	Year of Graduation
	ACT Score
	If you have not taken the ACT, when do you plan to take it?
.
EXTRACURRICULAR ACTIVITIES
	List Activities Involved In
	List Awards received
	List Activities You Plan to be Involved In at CRC
.
FAMILY INFORMATION
	Father's Name
Address if different from your own
	Mailing Address
	City
	State
	Zip
	Telephone
	Occupation

	Mother's Name
Address if different from your own
	Mailing Address
	City
	State
	Zip
	Telephone
	Occupation

	List all younger Brothers and Sisters (and year in school)
.
CHURCH PREFERENCE
	Name of Congregation
	Mailing Address
	City
	State
	Zip
	Are you a member?
	Name of Minister

.
CRIMINAL RECORD
	Have you ever been arrested by any law enforcement agency?
	If yes, give dates and details
.
GRADES AND STATEMENTS
	Grades are to be sent to:
.
FINANCIAL ASSISTANCE
	Are you claimed as a dependant by your parents or guardians for income tax purposes?

WAIVER OF RIGHT TO ACCESS TO CONFIDENTIAL INFORMATION NOTE: PLEASE READ BEFORE PROCEEDING Realizing the need for Crowley's Ridge College to obtain an objective opinion as to my qualification, I hereby waive my right of access to any confidential recommendations made for the purpose of determining my fitness for admission to this institution. I also authorize the release of any relevant information in regard to this application for admission.

AGREEMENT

Please type
"I agree" or "I do not agree"
waive my right of access in the box above

I certify that the preceding statements and information are correct and complete. If accepted for enrollment,
I pledge to abide by the the policies of
Crowley's Ridge College.

Full Name

Date