Danville Area
Community College 		       Student Information Form
When completing this form, please print clearly.
1. Social Security Number (for student I.D.)  ______________/_________/________________
2. Term: (check one)  Fall 20_____ Spring 20_____  Summer 20_____ 
3. Salutation: (check one)  Mr.  Mrs.  Miss  Ms.
4. Name: Last____________________  First____________________ Middle___________________ 
5. Previous Name(s) _______________________________________________________________ 
6. Permanent Legal, Home Mailing Address: 
No. & Street (Apt. No.) or Rural Route & Box Number _____________________________________
City or Town _______________ State (or Country) ______ Zip Code ________ County __________ 
7. Area Code & Phone Number
(_____)____________________		 8. Student e-mail address:
_____________________________________
9. Date of Birth ___________________________ 10. Gender  Male  Female
11. Citizenship or Visa 12. Racial Ethnic Group: Response is optional
U.S. Citizen
In U.S. on a Visa 
Expiration Date: __________
State Type of Visa: 
_____________________
Country of Citizenship: 
__________________
Applying for Student Visa
   
W 
 White (Non-Hispanic)
I 
 American Indian or Alaskan Native
A 
 Asian or Pacific Islander
B 
 African American (Non-Hispanic)
H 
 Hispanic
N 
 Non-Resident Alien/Foreign
13. Emergency Contact Name:
      Last___________________ First _________________ Phone (____)________________ 
 
14. Name of Major _____________________________________________
Career/Vocational (To prepare for work world) 
Transfer/Baccalaureate (To prepare for transfer to a four year college) 

15. High School Information: (check the name of the high school you last attended)
Armstrong 140-105 Danville 141-550 Jamaica 143-920 Schlarman 141-555
Bismarck 140-325 First Baptist 141-552 Milford 142-915 Seeger 153-750
Catlin 140-570 Fountain Central 153-580 North Vermillion 150-455  Shiloh 142-318
Chrisman 141-400 Georgetown-Ridge Farm 142-030  Oakwood 141-915 Westville 144-375
Covington 150-655  Hoopeston 142-310 Rossville 143-755  
Other: __________________________________________________ State _______________________ 

16. High School Information: (check one)
Graduated: Month and year of high school graduation __________/__________ 
Graduated: Month and year of GED awarded (Fill in line below) __________/__________ 
       County and state where GED was issued ______________________________
Currently in High School or taking GED classes
Did not graduate or receive GED
 
17. List all previous colleges or universities attended
Name of School
City/State
Attended From/To
Date Graduated
 ____________________   ____________________   ________/________   ________/________ 
 ____________________   ____________________   ________/________   ________/________ 
 
18. Enrollment Objective: (check one)
1–To complete one or several courses 
3–To complete a certificate of one year or more 		 2–To complete a certificate of less than one year
4–To complete an associate degree

19. Highest Previous Degree Earned: (check one)
H–High School 
B–Bachelor’s Degree
 		 G–GED 
M–Master’s Degree
 		 C–Certificate
D–PhD 
 		 A–Associate Degree
N–None (Includes high school 
    students who have not graduated

20. Employment Status:
1–Employed full time 
4–Homemaker		 2–Employed part time (over 15 hours) 
5–Unemployed/Retired		 3–Employed part time (15 hours or less)
6–Other
21. What is the highest degree/education level your mother/father/legal guardian completed?
Mother
Father
or    Legal Guardian
None Completed 
High School/GED
Some College 
Associate Degree
Bachelor’s Degree

22. Enrollment Status:
1–First time student College-Level (enrolled in 50% or more in college level classes)
2–First time student Developmental or Adult Education (enrolled in 50% or more in adult ed or dev. ed classes)
3–Transfer Student (earned college credit at another college, first term at DACC)
4–B&EI Enrollment (enrolled in 50% or more in B&EI classes)
5–Continuing Student (enrolled at DACC the previous term)
6–Move from Developmental or Adult Ed. to College-Level 
      (enrolled in 50% or more in college-level classes, previously in 50% or more dev. or adult ed.)
7–Re-admitted Student (prior DACC enrollment, not previous term)
23. Attendance Goal: (check one)
1–To prepare for transfer to a four-year college or university.
2–To  improve skills for my present job.
3–To prepare for a future job immediately after attending the community college.
4–To prepare for the GED test or improve basic academic skills.
5–For personal interest/self-development–not career-oriented.
6–Unknown.
24. Transfer Plans: (check one)
1–Not planning to transfer. 
2–Yes, I plan to transfer to a four-year college or university.
25. Is English your native language?  Yes  No
Signature_______________________________________________ Date ____________________ 
FOR OFFICE USE ONLY:
Minimum Admission Requirements for Associate of Arts & Associate of Science Degree Students
0–Not applicable/Not A.A., A.S., A.S.A., or A.E.S.
1–Yes, through high school coursework the student met all admission standards.
2–Yes, through means other than high school coursework (testing, college coursework, etc.) the student met all admission requirements.
3-No, student was evaluated but has not met all admission standards.
4–Not evaluated or data not available.
Term Admission Requirements Met.
1 - Summer 3 - Fall 6 - Spring

Fiscal Year Admission Requirements Met.
20_____