ADMISSIONS APPLICATION

ADMISSIONS APPLICATION
ENROLLMENT INFORMATION
SEMESTER *

Fall 2021 Spring Mini Semester 2021 (March) Summer 2021
PROGRAM (PICK ONE): *

MEDICAL BILLING AND CODING MEDICAL OFFICE ADMNISTRATIVE ASSISTANT START
STUDENT INFORMATION
Today's Date *
LAST NAME *
FIRST NAME *
MIDDLE INITIAL
Social Security Number *
Date of Birth *
OTHER/ MAIDEN NAME (IF APPLICABLE)
MAILING ADDRESS *
CITY,STATE, ZIP *
PARISH *
Cell Phone Number *
Email Address *
EMERGENCY CONTACT INFORMATION
Contact Name *
Relationship *
Contact Number *
DEMOGRAPHIC INFORMATION
RACE/ETHNICITY
ARE YOU OF HISPANIC / LATINO ORIGIN? *

YES NO
CHECK ALL THAT APPLY: *

AMERICAN INDIAN OR NATIVE AMERICAN ASIAN BLACK OR AFRICAN AMERICAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER WHITE
GENDER
LEGAL SEX: *

MALE FEMALE
GENDER IDENTITY (OPTIONAL)
MALE FEMALE NON-BINARY PREFER NOT TO SAY
CITIZENSHIP
ARE YOU A UNITED STATES CITIZEN? *

YES NO
EDUCATION INFORMATION
COLLEGES ATTENDED
NAME OF INSTITUTION
NAME OF INSTITUTION
CITY, STATE
CITY, STATE
DATES ATTENDED FROM: MM/YY TO: MM/YY
DATES ATTENDED FROM: MM/YY TO: MM/YY
DEGREE/DIPLOMA/CERTIFICATE
DEGREE/DIPLOMA/CERTIFICATE
HIGH SCHOOL
HIGH SCHOOL DIPLOMA *

YES NO
IF YES, YEAR COMPLETED
SCHOOL NAME:
CITY, STATE
HIGH SCHOOL EQUIVALENCY
GED OR EQUIVALENT? *

YES NO
IF YES, YEAR COMPLETED
HIGHEST GRADE COMPLETED
SCHOOL NAME:
CITY, STATE
UNDERGRADUATE/POST SECONDARY
ARE YOU CURRENTLY ATTENDING COLLEGE? *

YES NO
IF YES, CURRENT STATUS:

FRESHMAN SOPHOMORE JUNIOR SENIOR
HAVE YOU EVER ATTENDED GOODWILL TECHNICAL COLLEGE?

YES NO
CERTIFICATION OF SELECTIVE SERVICE REGISTRATION

FOR MALE APPLICANTS
I CERTIFY THAT I AM NOT REQUIRED TO REGISTER WITH SELECTIVE SERVICES BECAUSE (CHECK ONE): *

I AM FEMALE I WAS BORN BEFORE 1960 I AM A MEMBER OF THE ARMED FORCES ON ACTIVE DUTY I AM A VETERAN I AM NOT 18 YEARS OF AGE
NOTE: MEMBERS OF THE RESERVE NATIONAL GUARD ARE NOT CONSIDERED ACTIVE DUTY

I CERTIFY THAT I AM REGISTERED WITH SELECTIVE SERVICE
SELECTIVE SERVICE NUMBER
ADDITIONAL INFORMATION
(CHECK ALL THAT APPLY) ARE YOU A?

VETERAN ACTIVE US MILITARY DEPENDENT OF US VETERAN NATIONAL GUARD OR ACTIVE RESERVE
IF YOU ARE/WERE A PART OF THE MILITARY, WHICH BRANCH?

ARMY NAVY AIR FORCE MARINES COAST GUARD
ARE YOU PLANNING TO USE VETERANS EDUCATION BENEFITS?

YES NO
ARE YOU ELIGIBLE FOR TUITION ASSISTANCE ? *

YES- SEE NEXT QUESTION NO
TUITION ASSISTANCE SOURCES (CHECK ALL THAT APPLY)

LOUISIANA REHABILITATION SERVICES (LRS) SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) WIOA- LOUISIANA WORKFORCE COMMISSION (i.e. JOB 1)
DO YOU REQUIRE REASONABLE ACCOMMODATIONS? *

YES NO
IF YES, PLEASE PRINT AND COMPLETE ATTACHED GTC ACCOMMODATION FORM
AUTHORIZATION (CHECK ALL THAT APPLY)
*

I CERTIFY ALL INFORMATION IN THIS APPLICATION (INCLUDING SUPPLEMENTAL INFORMATION) IS FACTUALLY TRUE AND HONESTLY PRESENTED AND I AM THE PERSON SUBMITTING THIS APPLICATION. I CERTIFY THAT BY SIGNING THIS APPLICATION I HAVE INCURRED A $10.00 APPLICATION FEE AND THAT IS NONREFUNDABLE. ALL MATERIALS SUBMITTED FOR APPLICATION BECOME THE PROPERTY OF GOODWILL TECHNICAL COLLEGE AND WILL NOT BE RETURNED TO THE APPLICANT. I GIVE PERMISSION FOR GTC TO RELEASE INFORMATION TO POTENTIAL EMPLOYERS AS PART OF THE JOB PLACEMENT SERVICE PROVIDED BY THE COLLEGE AND TO OBTAIN EMPLOYMENT INFORMATION NEEDED FOR ACCREDITING PURPOSES.
GOODWILL INDUSTRIES OF SOUTHEASTERN LOUISIANA, INC./GOODWILL TECHNICAL COLLEGE DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, SEX, GENDER IDENTITY, SEXUAL ORIENTATION, RELIGION, AGE, VETERAN STATUS, OR DISABILITY IN EMPLOYMENT OR APPLICATION FOR EMPLOYMENT, ADMISSIONS, OR THE PROVISION OF SERVICES AND PROVIDES, UPON REQUEST, REASONABLE ACCOMMODATIONS NECESSARY TO AFFORD INDIVIDUALS WITH DISABILITIES EQUAL ACCESS TO PARTICIPATE IN ALL PROGRAMS AND ACTIVITIES; IN PARTICULAR AND WITHOUT LIMITING THE PRECEDING AND PURSUANT TO AND CONSISTENT WITH THE REQUIREMENTS OF TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 AND ITS REGULATIONS 34 CFR 100 ET SEQ.; SECTION 504 OF THE REHABILITATION ACT OF 1973 AND ITS REGULATIONS 34 CFR 104, SEX (TITLE IX OF THE EDUCATION AMENDMENTS OF 1972), DISABILITY (SECTION 504 OF THE REHABILITATION ACT OF 1976 IN ATTAINING EDUCATIONAL GOALS AND OBJECTIVES AND IN THE ADMINISTRATION OF PERSONNEL POLICIES AND PROCEDURES. FOR INQUIRIES OR MORE INFORMATION REGARDING THIS POLICY CONTACT THE EQUAL EMPLOYMENT OPPORTUNITY COMMISSION (EEOC) AT 1-800-669-4000.
EQUAL OPPORTUNITY STATEMENT/ APPLICANT SIGNATURE *
Date *
Should be Empty:

ADMISSIONS APPLICATION

ENROLLMENT INFORMATION

STUDENT INFORMATION

EMERGENCY CONTACT INFORMATION

DEMOGRAPHIC INFORMATION

RACE/ETHNICITY

GENDER

GENDER IDENTITY (OPTIONAL)

CITIZENSHIP

EDUCATION INFORMATION

COLLEGES ATTENDED

HIGH SCHOOL

HIGH SCHOOL EQUIVALENCY

UNDERGRADUATE/POST SECONDARY

CERTIFICATION OF SELECTIVE SERVICE REGISTRATION

ADDITIONAL INFORMATION

AUTHORIZATION (CHECK ALL THAT APPLY)