Personal Information

First Name*

Middle Name

Last Name*

Preferred Name

Mailing Address*

City*

State*

County*

Country*

Zip Code*

Home Phone

Cell Phone

Email*

Social Security Number*

Date of Birth*

Drivers License State

Drivers License Number

Gender*

Marital Status*

Children

Ethnicity*

Are you a legal citizen of the United States?*

Yes

Do you give permission to your parent(s)/guardian(s) to discuss your CRC account?* (This includes access to your grades, billing, scholarships, financial aid, etc.)

If you give permission, please list those with whom we may discuss your account

Education Information

High School Name*

High School State*

If you currently have either an IEP or a 504, please mark the correct box below.

IEP

504

Do you plan to graduate high school or earn your GED?*

Have you taken the ACT or SAT?

Yes

If no, then when do you plan on taking it?

GPA

Highest ACT Score

Graduation year*

Highest SAT Score

Were you suspended or expelled from school? If so, what was the reason?

When are you wanting to attend CRC?

Semester*

Year*

What type of student will you be? *

What will be your major field of study?*

What are your housing plans?*

In high school, have you taken any AP, CLEP or DUAL ENROLLMENT classes? If so, please list the class(es).

CLEP

DUAL ENROLLMENT

If you are a transfer student, please list all colleges/universities that you have attended and the semester or years that you attended.

Did you leave your last college/university in good standing?

Yes

If no, please explain.

Athletic Information

Are you interested in playing college athletics while a student at CRC?

Yes

Religious Information

Are you aware that Crowley’s Ridge College is a Christian institution?*

Yes

I understand that, as a student, I will be required to:

Attend Chapel services Monday – Thursday & take a Bible class each semester.*

I understand

I do not understand

Religious affiliation

Church Name

FAFSA Information

Do you plan to complete the FAFSA (Free Application for Federal Student Aid)?*

Yes

Family & Emergency Contact Information

Check If :

Parents are divorced

Mother is remarried

Emergency Contact is Mother

Both parents are remarried

Father is remarried

Emergency Contact is Father

Name of Emergency Contact (If not a parent)

Number for Emergency Contact (If not a parent)

Are you claimed as a dependent by your parent(s) on their taxes?*

Yes

Father’s First Name

Father’s Last Name

Father is deceased

Did he attend CRC?

Yes

Father’s Address

Street address

City

State

Zip Code

Father’s Phone Number

Father’s Email

Title/Occupation

Employer

Mother’s First Name

Mother’s Last Name

Mother is deceased

Did she attend CRC?

Yes

Mother’s Address

Street address

City

State

Zip Code

Mother’s Phone Number

Mother’s Email

Title/Occupation

Employer

Legal Information

Have you ever been arrested by any law enforcement agency?*

Yes

If yes, what were the circumstances?

Have you been convicted of a misdemeanor or felony?*

Yes

If yes, what were the circumstances?

Realizing the need for Crowley’s Ridge College to obtain an objective opinion as to my ability to handle college level work and to positively add to the student experience, I hereby waive my right to access 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. I further certify that I have disclosed all relevant information in regard to this application.

Agreement 1*

Type either “I agree” or “I do not agree”

I hereby grant and authorize Crowley’s Ridge College the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of Crowley’s Ridge College and will not be returned. I hereby hold harmless, and release Crowley’s Ridge College from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrations or any other persons may make while acting on my behalf or on the behalf of my estate.

Agreement 2*

Type either “I agree” or “I do not agree”

Full Name

Today’s Date*