* Indicates a Required Field
Suffix
None
JR
SR
II
III
IV
What are your current pronouns?
--Please Select--
Any pronouns
Ask my pronouns
She/Her/Hers/Herself
She/They
He/Him/His/Himself
He/They
Xe/Xem/Xemself
Ze/Zir/Zirs/Zirself
They/Them/Theirs
Use my name as pronoun
Other pronouns or combo:
What is your date of birth?
Select Month
January
Febuary
March
April
May
June
July
August
September
October
November
December
Select Day
Select Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
CCC collects the information below to comply with federal and state reporting requirements and to ensure we appropriately serve the needs of our community. CCC does not discriminate based on any of the following information.
Have you ever served in the US military?
--Please Select--
Veteran
Current active Military
Current active Reserve/Guard
Immediate family member of veteran
Immediate family member of current service member
Not sure
Prefer Not To Answer
Not Applicable
Will you be using VA Education Benefits?
--Please Select--
Yes
No
Not Sure
Legal Sex, Gender Identity, and Sexual Orientation are used to identify students who are eligible for grants and services, and are used in data analyses to address equity issues at CCC.
What is your current gender identity?
--Please Select--
Woman
Man
Agender
Genderfluid
Gender Non-Conforming
Genderqueer
Non-Binary
Queer
Questioning
Trans Man
Trans Woman
Two Spirit
Prefer Not To Answer
Another, please write in:
What is your current sexual orientation?
--Please Select--
Asexual
Bi/Pan/Omni/Poly/Abro
Heterosexual
Homosexual
Queer
Questioning
Another, Please Write-In:
Prefer Not To Answer
What race(s) do you identify with?
Providing language information will help CCC better serve students. Please provide your native language, primary language, and list any other languages you speak.
What is your primary language?
--Please Select--
English
Spanish
Russian
Chinese
Vietnamese
Another, please write in:
Prefer Not To Answer
What is your native language?
--Please Select--
English
Spanish
Russian
Chinese
Vietnamese
Another, please write in:
Prefer Not To Answer
