Indicate whether your parent(s) or legal guardian(s) have completed a Baccalaureate Degree: Mother Father Legal Guardian None of these

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1 INDIAN RIVER STATE COLLEGE Application for Admission Office of Admissions and Records 3209 Virginia Avenue Fort Pierce, FL Applicants interested in Financial Aid or Veteran s Benefits, contact Student Services. Any applicant with a disability requiring assistance may contact the Student Disability Services Office on the Main Campus (772) or Last Name (Print legal name in full) Suffix (Jr., Sr., II, etc.) Social Security/ID Number (See compliance statement on back) - - First Name Middle Previous Name(s) Local Mailing Address City State Zip Code Country Permanent Address City State Zip Code Country Home Phone ( ) Date of Birth Mo/Day/Yr Country of Birth Country of Citizenship Immigration Status (C) U.S. Citizen (P) Permanent Resident Alien A- (T) Temporary Resident Alien A- (A) Asylee or Applicant for Asylum (L) Parolee (R) Refugee (V) Visa students other than F-1 ( ) Student applying for F-1 Visa Work Phone ( ) Cell Phone ( ) *PLEASE NOTE: Sex, Race, and Ethnicity are voluntary: Sex (M) Male (F) Female Ethnicity (H) Hispanic (N) Non-Hispanic Admission Code (H) High School Graduate or General Education Diploma (GED) (I) IRSC graduate (A.A., A.S. or A.A.S.) Race (A) Asian (B) Black or African American (I ) American Indian/Alaskan Native (P) Hawaiian or Pacific Islander (W) White Enrollment Status (N) New Student (C) Returning IRSC Student (T) Transfer - a student who has previously attended a college, university or technical school other than IRSC (O) Other - none of the above apply (C) Concurrent HS/College student that is non-dual enrollment Program of Study: # Select from programs listed on pages 5 and 6. A $30 application fee is ONLY required for Baccalaureate Programs. Term you plan to start enrollment: Fall (Aug) Spring (Jan) Summer I (May) Summer II (June) Campus for Student Services: Main/Fort Pierce Chastain/Stuart Mueller/Vero Beach Dixon Hendry/Okeechobee Pruitt/St. Lucie West Office Use Only Entered By: Campus: High School GED High school graduates should have an official transcript reflecting the high school graduation date sent to the Admissions Office, or present an original GED state diploma and score report prior to or during the first term of enrollment. Full Name of High School City State Country Graduation Date Mo/Day/Yr Prior College Attendance: List all colleges, universities, technical schools, etc., attended. Have official transcript(s) sent from each institution. Full Name of School or College City State Country Degree Earned Indicate whether your parent(s) or legal guardian(s) have completed a Baccalaureate Degree: Mother Father Legal Guardian None of these I certify that all the information submitted in this application is true to the best of my knowledge. I understand that any misrepresentation of facts may result in the immediate cancellation of my application or registration. Once admitted, I agree to abide by the policies of the Board of Trustees and the rules and regulations of the College. I understand that it is my responsibility to submit high school and/or postsecondary transcripts. I agree to the release of all transcripts and test scores to IRSC, including but not limited to SAT, Achievement Tests, and ACT score reports that IRSC may request from other educational institutions, school districts, the College Board, or ACT. Applicant s Signature: Signature of Parent /Legal Guardian of applicant under 18 years of age: Legal Guardian- a copy of court documents must be attached. Date: Date: IRSC 132 (Rev. 5/14) Page 1

2 NOTIFICATION OF SOCIAL SECURITY NUMBER COLLECTION AND USAGE In compliance with Florida Statute (5), this document serves to notify you of the purpose for the collection and usage of your Social Security number by Indian River State College (IRSC). IRSC collects and uses your Social Security number only if specifically authorized by law to do so or it is imperative for the performance of its duties and responsibilities as prescribed by law. Specifically, IRSC collects your Social Security number for the following purposes: Admissions Department Federal legislation relating to the Hope Tax Credit makes it mandatory that all postsecondary institutions report student Social Security numbers to the Internal Revenue Service (IRS). This IRS requirement makes it mandatory for colleges to collect the Social Security number of every student. A student may refuse to disclose his or her Social Security number to IRSC, but the IRS is then authorized to fine the student in the amount of $50. In addition to the federal reporting requirements, the public school system in Florida uses Social Security numbers as a student identifier (Florida Statutes ). In a seamless K-20 system it is non-mandatory; however, it is beneficial for postsecondary institutions to have access to the same information for purposes of tracking and assisting students in the smooth transition from one education level to the next. All Social Security numbers are protected by federal regulations Family Educational Rights and Privacy (FERPA). Financial Aid Department It is mandatory that the Office of Financial Aid at IRSC requires students to submit their Social Security numbers on various forms in order to correctly identify applicants, match each applicant s financial aid record with the student record, and to help coordinate state aid programs with institutional and federal aid programs as authorized by Sections 483 and 484 of the Higher Education Act of 1965, as amended. Outreach Programs Programs such as the Educational Opportunity Program and College Reach-Out Program are youth outreach projects funded by discretionary grants from the United States or Florida Departments of Education. As such, each project is required to exclusively serve eligible participants that are citizens or nationals of the United States; or are permanent residents of the United States. In order to verify a participant s project eligibility, it is mandatory that Social Security numbers are collected and also later used when submitting information for the Annual Performance Reports due to the United States or Florida Department of Education. Workforce Programs It is mandatory that these programs use Social Security numbers as an identifier for program enrollment and completion. Also, Social Security numbers are used for entering placement information into either the OSMIS or the Employ Florida Marketplace statewide data collection and reporting system. Because these are performance based contract programs, it is required that all participants and their program related activities be recorded in the Florida state system. Continuing Education, Corporate & Community Training Institute (CCTI) Because of Florida State Board of Education reporting requirements and Department of Business and Professional Regulations reporting requirements, it is mandatory for students who enroll in Continuing Education and/or CCTI courses and/or customized training seminars to submit their Social Security number. State and Federal Reporting It is mandatory that the College collects Social Security numbers to periodically report student/employee level data to federal and state agencies for research and data collection. Testing It is mandatory that the College collects Social Security numbers for the purpose of reporting state and national standardized testing results, including but not limited to: TABE, GED, FTCE, ACT, CLEP, HOBET. Miscellaneous It is mandatory to collect Social Security numbers for agency third party billings, payment collections, state and federal data collection, tracking, benefit processing, tax reporting, and for identification and verification. To protect your identity, IRSC will secure your Social Security number from unauthorized access and assign you a unique student identification number. This unique identification number will then be used for all associated employment and educational purposes at IRSC. Copies of the full IRSC Notification of Social Security Number Collection and Usage document can be obtained from Student Services at all IRSC campuses and at the IRSC website at GED is a registered trademark of the American Council on Education (ACE) and administered exclusively by GED Testing Service LLC under license. This material is not endorsed or approved by ACE or GED Testing Service. Indian River State College does not discriminate on the basis of race, color, national origin, ethnicity, sex, religion, age, disability, sexual orientation, marital status, veteran status or genetic information in its programs and activities. The following person has been designated to handle inquiries regarding non-discrimination policies: Adriene B. Jefferson, Dean of Minority Affairs/Equity Officer/Title IX Coordinator Indian River State College Main Campus 3209 Virginia Avenue Fort Pierce, FL (772) Revised 5/2014 Page 2

3 Statement of Residency Students shall be classified as residents or non-residents for the purpose of assessing tuition at Indian River State College based on the provisions of Florida Statute and State Board of Education Rule 6A To qualify for initial classification as a resident for tuition purposes, the student as an independent claimant, or the dependent student s parent or legal guardian as claimant, must have established and submitted proof of legal residence in Florida for at least 12 consecutive months immediately prior to the student s first term of enrollment. All U.S. citizen dependent students who meet the statutory requirements for Florida residency, regardless of parental immigration status in the U.S., will be classified as residents for tuition purposes. All non-u.s. citizen dependent students, along with their parent as claimant, must provide proof of an eligible immigration status in the U.S. in addition to meeting statutory requirements for residency for tuition purposes. I AM claiming in-state residency for tuition purposes. (Please complete Sections 1. and 2. below and submit this form to any campus.) I AM NOT claiming in-state residency for tuition purposes. (Please complete Section 3. below and submit this form to any campus.) 1. Florida Residents Student ID#/SSN* Student Name Date of Birth Please select one of the following residency classifications: A. I am an independent *Claimant who provides more than 50% of my own support and have maintained legal residence in Florida for at least 12 consecutive months. B. I am a dependent person eligible to be claimed by my parent or legal guardian as defined by the federal income tax code. My parent or legal guardian as *Claimant has maintained legal residence in Florida for at least 12 consecutive months. C. I am a dependent person who has resided for the last three years with an adult relative other than my parent or legal guardian, and my relative as *Claimant has maintained legal residence in Florida for at least 12 consecutive months. (Required: Copy of two (2) years tax returns verifying dependent status.) D. I am married to a *Claimant who has maintained legal residence in Florida for at least 12 consecutive months and I have now established Florida as my primary residence. (Required: Student must submit marriage license plus one legal tie to Florida; spouse as *Claimant must complete Section II.) E. I was enrolled at a Florida state institution of higher education within the previous 12 months and was classified as a Florida resident for tuition purposes. (Required: Official Transcript noting Florida residency.) F. I am a member of the U.S. armed services stationed in Florida on active military duty pursuant to military orders, or my home of record is Florida; or I am a member s spouse or dependent child; or I am an active drilling member of the Florida National Guard. (Required: Copy of military orders, L.E.S., or DD2058.) G. I am a full-time instructional or administrative employee of a Florida public school or institution of higher education, or I am the employee s spouse or dependent child. (Required: Letter of employment verification.) H. I am a full-time employee of a state agency or political subdivision of the state whose student fees are paid by the state agency or political subdivision for the purpose of job-related law enforcement or corrections training. (Out-of-state fee exemption will be processed by the Business Office.) J. I am a qualified beneficiary of the FL Prepaid College Program (FS ). (Required: Proof of Florida Prepaid.) Please attach a copy of required document(s). In some cases, additional documentation may be requested to validate marriage, dependency, or eligibility. 2. Person Claiming Florida Residency must complete this section in full and attach all required documentation. PLEASE PRINT. Two (2) documents per F.S (3)(c)1 and (c)2 supporting the establishment of legal residence must be submitted and dated, issued, or filed 12 months before the first day of classes for the term for which Florida residency classification is sought. All documentation is subject to verification through Florida state databases. 1. *Claimant Name: 2. Relationship to Student: 3. Claimant Address: City State Zip Code 4. Claimant Telephone#: ( ) 5. Date Claimant established legal Florida residence and domicile: / / County: 6. U.S. Citizen Permanent Resident Alien # (I 551 Card required) Other VISA (Proof required) 7. Claimant s Residency Documentation: (Please complete two (2) of the following.) Voter Registration: Driver License: Vehicle Registration: State: Number: County: Issue Date: / / State: Number: Issue Date: / / State: Tag Number: Issue Date: / / Other Document(s) Attached: State: Description: Issue Date: / / I do hereby swear or affirm that the above named student meets all requirements indicated in the checked category above for classification as a Florida resident for tuition purposes. I understand that a false statement in this affidavit will subject me to penalties pursuant to , Florida Statutes, and to FBOE Rule 6C F.A.C. Signature of person claiming Florida residency IRSC-132A (Revised 4/2014) Date *See Social Security compliance statement on back 3. NON FLORIDA RESIDENTS ONLY Name: Student ID/SSN*: Signature: IRSC-132A Revised 5/2014 Page 3

4 NOTIFICATION OF SOCIAL SECURITY NUMBER COLLECTION AND USAGE In compliance with Florida Statute (5), this document serves to notify you of the purpose for the collection and usage of your Social Security number by Indian River State College (IRSC). IRSC collects and uses your Social Security number only if specifically authorized by law to do so or it is imperative for the performance of its duties and responsibilities as prescribed by law. Specifically, IRSC collects your Social Security number for the following purposes: Admissions Department Federal legislation relating to the Hope Tax Credit makes it mandatory that all postsecondary institutions report student Social Security numbers to the Internal Revenue Service (IRS). This IRS requirement makes it mandatory for colleges to collect the Social Security number of every student. A student may refuse to disclose his or her Social Security number to IRSC, but the IRS is then authorized to fine the student in the amount of $50. In addition to the federal reporting requirements, the public school system in Florida uses Social Security numbers as a student identifier (Florida Statutes ). In a seamless K-20 system it is non-mandatory; however, it is beneficial for postsecondary institutions to have access to the same information for purposes of tracking and assisting students in the smooth transition from one education level to the next. All Social Security numbers are protected by federal regulations Family Educational Rights and Privacy (FERPA). Financial Aid Department It is mandatory that the Office of Financial Aid at IRSC requires students to submit their Social Security numbers on various forms in order to correctly identify applicants, match each applicant s financial aid record with the student record, and to help coordinate state aid programs with institutional and federal aid programs as authorized by Sections 483 and 484 of the Higher Education Act of 1965, as amended. Outreach Programs Programs such as the Educational Opportunity Program and College Reach-Out Program are youth outreach projects funded by discretionary grants from the United States or Florida Departments of Education. As such, each project is required to exclusively serve eligible participants that are citizens or nationals of the United States; or are permanent residents of the United States. In order to verify a participant s project eligibility, it is mandatory that Social Security numbers are collected and also later used when submitting information for the Annual Performance Reports due to the United States or Florida Department of Education. Workforce Programs It is mandatory that these programs use Social Security numbers as an identifier for program enrollment and completion. Also, Social Security numbers are used for entering placement information into either the OSMIS or the Employ Florida Marketplace statewide data collection and reporting system. Because these are performance based contract programs, it is required that all participants and their program related activities be recorded in the Florida state system. Continuing Education, Corporate & Community Training Institute (CCTI) Because of Florida State Board of Education reporting requirements and Department of Business and Professional Regulations reporting requirements, it is mandatory for students who enroll in Continuing Education and/or CCTI courses and/or customized training seminars to submit their Social Security number. State and Federal Reporting It is mandatory that the College collects Social Security numbers to periodically report student/employee level data to federal and state agencies for research and data collection. Testing It is mandatory that the College collects Social Security numbers for the purpose of reporting state and national standardized testing results, including but not limited to: TABE, GED, FTCE, ACT, CLEP, HOBET. Miscellaneous It is mandatory to collect Social Security numbers for agency third party billings, payment collections, state and federal data collection, tracking, benefit processing, tax reporting, and for identification and verification. To protect your identity, IRSC will secure your Social Security number from unauthorized access and assign you a unique student identification number. This unique identification number will then be used for all associated employment and educational purposes at IRSC. Copies of the full IRSC Notification of Social Security Number Collection and Usage document can be obtained from Student Services at all IRSC campuses and at the IRSC website at GED is a registered trademark of the American Council on Education (ACE) and administered exclusively by GED Testing Service LLC under license. This material is not endorsed or approved by ACE or GED Testing Service. Indian River State College does not discriminate on the basis of race, color, national origin, ethnicity, sex, religion, age, disability, sexual orientation, marital status, veteran status or genetic information in its programs and activities. The following person has been designated to handle inquiries regarding non-discrimination policies: Adriene B. Jefferson, Dean of Minority Affairs/Equity Officer/Title IX Coordinator Indian River State College Main Campus 3209 Virginia Avenue Fort Pierce, FL (772) Revised 5/2014 Page 4

5 PROGRAM of STUDY CODE LIST An [S] by the program code below denotes a program which has specific application deadlines and admission requirements. Consult with an IRSC advisor or the IRSC website. BACCALAUREATE DEGREES Applicants for the Baccalaureate Degree programs must have earned an Associate Degree (or equivalent) from a regionally accredited college or university. Bachelor of Applied Science in Digital Media with Concentration in: R0040 Graphic Design and Visual Communication R0060 Animation, Gaming and Modeling Bachelor of Applied Science in Organizational Management: R0010 Organizational Management Bachelor of Science in Accounting: S0170 Accounting Bachelor of Science in Biology: S0070 Biology Bachelor of Science in Business Administration: S0110 Business Administration Bachelor of Science in Criminal Justice: S0120 Criminal Justice Bachelor of Science in Education: S0010 Exceptional Student Education/ESOL S0020 Middle Grades Math S0030 Secondary Math S0040 Middle Grades Science S0050 Secondary Biology S0160 Elementary Education Bachelor of Science in Healthcare Management: S0180 Healthcare Management Bachelor of Science in Human Services with Concentration in: S0080 Human Services Generalist S0090 Youth and Family Studies S0100 Addictions Studies Bachelor of Science in Information Technology Management and Cybersecurity: S0130 Information Technology Management and Cybersecurity Bachelor of Science in Nursing: S0060 Nursing Bachelor of Science in Public Administration with Concentration in: S0140 Emergency Planning & Management S0150 Public Policy & Leadership A $30 application fee is required for all Baccalaureate programs. ASSOCIATE in ARTS DEGREES (A.A.) The Associate in Arts Degree recognizes completion of the first two years of college through a solid academic program designed to provide students with the foundation to continue their studies toward a Baccalaureate Degree at Indian River or other upper-division colleges and universities. Graduates with an A.A. Degree are guaranteed the right to transfer as juniors into Florida s public university system Accounting Agricultural (Food & Resource) Economics Agriculture (General) Anthropology Architecture Art (General) Biology Biotechnology Business Administration Chemistry Computer and Information Sciences Computer Sciences Criminal Justice Dietetics/Nutrition Digital Media Economics (Business) Economics (Social Sciences) Education (Elementary/Special) Education (Secondary) Engineering English Environmental Science Film Finance/Marketing Foreign Language Forestry/Wildlife Ecology & Conservation History Humanities IRSC 132B (Rev. 10/22/13) Human Services Informational Technology Management & Cybersecurity Journalism/Public Relations Marine Science Mathematics Music Musical Theatre Music Therapy Nursing Occupational Therapy Organizational Management Parks and Recreation Management Pharmacy Philosophy Physical Education Physics Political Science Pre-Medicine/Pre-Veterinary/Pre-Physical Therapy Psychology Public Administration Social Work Sociology Theatre/Dramatic Arts ASSOCIATE in SCIENCE DEGREES (A.S.) ASSOCIATE in APPLIED SCIENCE DEGREES (A.A.S.) The Associate in Science and Associate in Applied Science degrees are two-year programs of study designed to provide students with the academic and technical skills necessary for success in 21 st century careers. Graduates with an A.S. or A.A.S. Degree are prepared to enter their chosen career field and/or continue their education toward a Baccalaureate Degree at Indian River or other upper-division colleges or universities Accounting Technology A0010 Agricultural Production Technology A0020 Air Conditioning, Refrigeration, and Heating Systems Technology Architectural Design & Construction Technology A0030 Automotive Service Management Technology Building Construction Technology Business Administration Civil Engineering Technology Computer Information Technology Criminal Justice Technology (A.S.) Culinary Management [S] Dental Assisting Technology & Mgmt [S] Dental Hygiene [S] A0050 Dental Laboratory Technology & Management Digital Media Technology Drafting and Design Technology Early Childhood Education Electrical Power Technology A0060 Electronics Engineering Technology Emergency Administration & Management [S] Emergency Medical Services Fire Science Technology A0070 Golf Course Operations Graphics Technology [S] Health Information Technology [S] Health Services Management Human Services Interior Design Technology A0080 Landscape & Horticulture Technology Marketing Management [S] Medical Laboratory Technology [S] Nuclear Medicine Technology [S] Nursing Associate Degree R.N Paralegal Studies/Legal Assisting [S] Physical Therapist Assistant [S] Radiography [S] Respiratory Care A0090 Restaurant Management Theatre & Entertainment Technology Page 5

6 PROGRAM of STUDY CODE LIST (continued) An [S] by the program code below denotes a program which has specific application deadlines and admission requirements. Consult with an IRSC advisor or the IRSC website. TECHNICAL CERTIFICATES (TC) Technical Certificate programs are components of Associate in Science or Associate in Applied Science Degree programs. They provide a student with the opportunity to obtain a specific skill set for employment and at the same time build a foundation to continue on to an Associate Degree program Accounting Applications Aquaculture Technology AutoCad Foundations Automotive Service Technician Basic Electronics Business Management Business Management (Career Dev Program) Chef s Apprentice Child Care Center Management Specialization Child Development and Early Intervention CISCO Certified Network Assoc Computer Programming Specialist Culinary Arts Culinary Arts Management Operations Digital Media Production Digital Media Support Drafting Electronic Technology Emergency Management Entrepreneurship Certificate Graphic Design Production Graphic Design Support Homeland Security Emergency Manager Home Staging Information Technology Support Kitchen & Bath Design Landscape & Horticulture Specialist Landscape & Horticulture Professional Landscape & Horticulture Technician Lasers & Photonics Marketing Operations [S] Nuclear Medicine Technology Specialist Office Specialist [S] Paramedic Preschool Specialization Solar Energy Technician Web Production APPLIED TECHNOLOGY DIPLOMAS (ATD) Applied Technology Diplomas are components of Associate in Science or Associate in Applied Science Degree programs. They provide a student with the opportunity to obtain a specific skill set for employment and at the same time build a foundation to continue on to an Associate Degree program. These programs require a high school diploma to be admitted. [S] B0050 Dental Assisting Technology & Mgmt [S] B0010 Emergency Medical Technician B0020 Pest Control Operations B0030 Turf Equipment ADVANCED TECHNICAL CERTIFICATES (ATC) Advanced Technical Certificate programs are available to students who have already been awarded an Associate in Science Degree and wish to upgrade their skills. [S] Advanced Respiratory Care Practice [S] Manual Techniques for the PTA [S] Perioperative Nursing [S] PET/CT ATC VOCATIONAL CERTIFICATES (VC) CAREER TRAINING PROGRAMS Vocational Certificate programs emphasize specific skill development, some leading to licensure or certification Administrative Assistant Advanced Esthetics Air Conditioning, Refrigeration, and Heating Apprenticeship Air Conditioning, Refrigeration, Heating Air Conditioning, Refrigeration, Heating Automotive Service Tech Automotive Service Tech Auxiliary Law Enforcement Officer Barbering Carpentry [S] Central Service Technology Commercial Vehicle Driving [S] Correctional Officer- Basic Recruit Training [S] Corrections Officer Crossover from Law Enforcement Officer Cosmetology Cosmetology Specialist- Facials Cosmetology Specialist - Nails Culinary Operations Apprenticeship Early Childhood Education Electrical Apprenticeship [S] Firefighting Basic Recruit Training [S] Law Enforcement Basic Recruit Training [S] Law Enforcement Officer Crossover from Correctional Officer Legal Administrative Specialist Line Erector Apprenticeship Masonry Apprenticeship Medical Administrative Specialist [S] Medical Assisting [S] Patient Care Assistant [S] Pharmacy Technician [S] Phlebotomy Plumbing Apprenticeship [S] Practical Nursing Private Security Officer [S] Supported Competitive Employment [S] Surgical Technology [S] Vocational Ed for Students with Disabilities Welding Technology (Applied) EDUCATOR PREPARATION INSTITUTE F0020 Educator Preparation Institute NON-DEGREE SEEKING STUDENTS 300DE Dual Enrollment Taking Associate-level classes for employment purposes Taking Associate-level classes for other personal objectives H0010 Taking Baccalaureate-level classes for employment purposes H0020 Taking Baccalaureate level classes for personal objectives 300TS Transient Student-Lower Division H00TS Transient Student-Upper Division IRSC 132B (Rev. 10/22/13) Page 6

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