DocuSign Envelope ID: 782389EC-4A47-4174-9C15-BC8EF47340C8

Admissions Application Form

Please select the campus

you would like to attend: Signal Peak (8470 N. Overfield Rd., Coolidge, AZ 85128)

Personal Information
First Name: Maricela
Middle Name: Adilene
Last Name: Rivas

Maiden or Previous Last Name:

Social Security Number:* 601-91-8871

If you do not have a SSN, please indicate ‘111-11-1111’ above & check box HERE:
09/19/1999
Date of Birth (MM/DD/YYYY)
US Citizen
Citizen:
Single
Marital Status:
Female
Gender:

Email Address: [email protected]

5204245010
Mobile Phone Number:

Home Phone Number:

224 N E st
Mailing Address:
Eloy
City:
AZ
State:
85131
Postal Code:

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DocuSign Envelope ID: 782389EC-4A47-4174-9C15-BC8EF47340C8

Admissions Application Form

Emergency Contact
First Name: Diana
Last Name: Rivas
Relationship: Mother
Home Phone Number:

Mobile Phone Number: 5205827917

Email Address: [email protected]

Do you authorize this person to take possession of your

Yes
personal property in the event of an emergency?:

Educational Information
What is your current student status?:
(Select one type that best describes your status) Continuing Education

Select your degree or certificate based upon an Area of Interest below. Click Here for More on Areas of Interest

Biological/Physical Sciences & Agriculture

Business & Professional Industries
Communication & English
Computer Technology, Engineering & Math
X Education
Industrial Technology & Skilled Trades
Nursing, Health & Emergency Careers
Social/Behavioral Science & Public Services
Visual, Fine, & Performing Arts
Non-Degree Seeking

Early Childhood Education (Associate of Arts)

When do you plan to start taking classes?: Spring 2022

Please indicate your highest level of education completed: High School

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DocuSign Envelope ID: 782389EC-4A47-4174-9C15-BC8EF47340C8

Admissions Application Form

Educational Information, Continued

High School/GED State:
Arizona
High School/GED Name: Casa Grande Union
Graduation Date or Expected Graduation (MM/DD/YYYY): 05/22/2018

Failure to disclose previous college(s) is a violation of the Student Code of Conduct and is grounds for denial of admission or immediate
suspension if enrolled. It is the responsibility of the student to provide official transcripts from all institutions indicated above for prior credit
evaluation. In addition, all students receiving Financial Aid must declare a program of study and provide official transcripts from previous
institutions attended.

If you have a high school or college transcript,

please upload for review.

Ethnicity/Race Information
Are you of Hispanic ethnicity?: X Yes No

Race (Check ALL That Apply):

American Indian or Alaskan Native

Asian
Black or African American
Native Hawaiian or other Pacific Islander

X White

Tribe:

Military/Veteran Students
Are you a veteran of U.S Armed Forces?:
No
Do you plan to use Veteran Educational Benefits?: No

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DocuSign Envelope ID: 782389EC-4A47-4174-9C15-BC8EF47340C8

Admissions Application Form

Residency Acknowledgement
These questions are asked for the purpose of determining tuition and fees. State law requires that a
person who is not a citizen or legal resident of the United States or who is without lawful immigration
status is not entitled to classification as an in-state student pursuant to A.R.S. 15-1802 or entitled to
classification as a county resident pursuant to A.R.S. 15-1802.01. Failure to answer questions may
result in being classified as out-of-state for tuition and fees purposes.

The responsibility for registering under the proper residency classification at the time of admission is
placed upon the student. Any student who falsifies their residency may be subject to dismissal from
the college and/or criminal action. Refer to the college catalog for residency guidelines.

For in-state tuition purposes, you must reside in Arizona for one complete year to establish residency.

Are you a legal Arizona resident?: Yes

What date did your present stay begin?:

Do you have an Arizona Driver’s License or Government

Yes
Issued Identification card?**:

IF YES: Upload Driver’s License or Government ID:

A clear image of the front side of your ID card is sufficient.
If you do not include a copy of your Driver’s License or Government Issued
ID, you will be classified as an out-of-state resident. As an out-of-state
resident, your tuition and fees are double that of an in-state resident.
For in-state residency, you must have lived in AZ for at least one year.
Contact [email protected] for additional information.

Driver’s License State:

Arizona
Driver’s License Number: D09278597
IF NO: Upload Alternate Identification such as
High School ID and Birth Certificate or Other:

Are you seeking admissions under the Western

Undergraduate Exchange (WUE) program? No

If yes, please identify your WUE home state:

Students from participating WUE states pay no more than 150% in-state tuition. Students must provide proof of WUE
residency.

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DocuSign Envelope ID: 782389EC-4A47-4174-9C15-BC8EF47340C8

Admissions Application Form

You must agree to the terms below or your application may not be processed.

I understand that withholding information requested on this application, including all prior attendance
at other institutions, or giving false information, may make me ineligible for admission or subject to
dismissal. I have read this application and certify that all statements herein are correct and complete.

In addition, I consent to electronic delivery of institutional business, including but not limited to,
admission, registration, billings, direct deposits and delivery of Form 1098-T.

10/8/2021

*After completing the admissions process, all students are assigned a Student ID Number that will be used for all future
transactions.
All students receiving Financial Aid must provide a valid Social Security Number, declare a program of interest and provide
official transcripts from previous institutions attended. In addition, any student that is in need of a 1098-T for federal tax
purposes must also provide a valid Social Security Number at the time of admissions.

**If you do not have a valid form of identification, please call the Central Help Desk at 520-494-5111 or email
[email protected] for assistance.

Note:
Please allow 24 hours for processing of your application during regular business hours (Monday-
Thursday, 8:00 am – 6:00 pm). You will receive an admissions letter via email to the address provided
in your application.

This letter will contain important student information, including your student ID number, as well as
username and temporary password for your CAC Student Portal, CAC email and Blackboard accounts.

Please add [email protected] to your email safe list. Questions? [email protected].

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DocuSign Envelope ID: 782389EC-4A47-4174-9C15-BC8EF47340C8