Application for Admission

Personal Information
Name Last Phone ( Address Gender: Female Country of Birth Emergency Contact Male Date of Birth Country of Citizenship Phone ( ) / / ) First MI Work/Cell ( ) Previous Name If Any Email City/State/Zip Student ID Primary Language Work/Cell ( ) *SSN -

Ethnicity: (Race as defined by the State of Florida Department of Education.)

White (Non-Hispanic) Hispanic African American Multi-racial Asian Native American Pacific Islander

Educational Information
Last School Attended Have you officially withdrawn from this school? Yes ESE: Yes No ESOL: Yes No No City and State If yes, date withdrawn: (mm/yyyy) Grade

Parent/ Guardian/Community Member Info

Name Address Phone/Cell ( Employer: ) Email Work # ( )

Class Offenses
Have you ever been charged with a Class III offense or sent to an alternative school? Yes Have you ever been convicted of a felony? Yes No No Not Sure

The Florida State College at Jacksonville provides equal access to education, employment, programs, services and activities and does not discriminate on the basis of age, race, color, national origin, sex, disability, religious belief, or marital status. The College Equity Officer has been designated to handle inquiries regarding the non-discrimination policies and may be contacted at equityofficer@fscj.edu.

Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere. Pathways Academy is a division of Florida State College at Jacksonville.

Florida State College at Jacksonville is accredited by the Commission on Colleges of the Southern Association of Colleges and Schools (SACSCOC) to award the baccalaureate and associate degree. Contact the Commission on Colleges at 1866 Southern Lane, Decatu r, Georgia 30033-4097, or call (404) 679-4500 for questions about the accreditation of Florida State College at Jacksonville. The Commission is to be contacted only if there is evidence that appears to support an institution's significant non-compliance with a requirement or standard. *For more information regarding the Collection and Use of Social Security Numbers (http://www.fscj.edu/ssn)

Application for Admission

, the applicant or I,

, parent or legal guardian, if the applicant is less than / /

18 years of age, am a bonafide resident and domiciliary of the State of Florida. I have lived in Florida since: (mm/dd/yyyy)

I declare under penalty of perjury punishable by law as a misdemeanor under Section 837.06, Florida Statutes, that the foregoing is true and correct. To be completed by Student

I hereby apply for admission to Florida State College at Jacksonville and agree to abide by all rules and regulations of the college. I understand that Florida State College at Jacksonville will not release official transcripts to any other schools/organizations until verification of high school graduation is received and the Record Change Form is completed to change my admission status I understand that to continue enrollment at Florida State College at Jacksonville after graduation, I must submit a Record Change Form to change my admission status. I have checked this application for errors and certify that the information is accurate and complete. Date Date / / / /

Applicant Signature Parent/Guardian Signature

The Florida State College at Jacksonville provides equal access to education, employment, programs, services and activities and does not discriminate on the basis of age, race, color, national origin, sex, disability, religious belief, or marital status. The College Equity Officer has been designated to handle inquiries regarding the non-discrimination policies and may be contacted at equityofficer@fscj.edu.

Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere. Pathways Academy is a division of Florida State College at Jacksonville.

Florida State College at Jacksonville is accredited by the Commission on Colleges of the Southern Association of Colleges and Schools (SACSCOC) to award the baccalaureate and associate degree. Contact the Commission on Colleges at 1866 Southern Lane, Decatu r, Georgia 30033-4097, or call (404) 679-4500 for questions about the accreditation of Florida State College at Jacksonville. The Commission is to be contacted only if there is evidence that appears to support an institution's significant non-compliance with a requirement or standard. *For more information regarding the Collection and Use of Social Security Numbers (http://www.fscj.edu/ssn)