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City College of San Francisco Student Application
Student
Note: Completion of this form will immediately send your application request to an Umoja coordinator.
First Name
*
Middle Name
Last Name
*
Student ID
Birth Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
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4
5
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31
Year
Year
1924
1925
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1927
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1932
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1934
1935
1936
1937
1938
1939
1940
1941
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1990
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Race/Ethnicity
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White
Native Hawaiian or other PI
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Street Address
Street Address Line 2
Street Address Line 3
City
Postal Code
Country
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Albania
Algeria
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Angola
Anguilla
Antarctica
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Aruba
Australia
Austria
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Belgium
Belize
Benin
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Bouvet Island
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Burundi
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Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
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Colombia
Comoros
Congo, Republic of the
Congo, The Democratic Republic of the
Cook Islands
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Croatia
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Curaçao
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Faroe Islands
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Gambia
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Greenland
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Hungary
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Indonesia
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Iraq
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Kosovo
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Thailand
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Turkey
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Virgin Islands, U.S.
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State/Province
Phone Number
Email
*
Age
- None -
18-21
22-25
26 and up
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Are you a first generation college student (neither parent is a college graduate)?
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No
Student Status
- None -
New
Continuing
Returning
Transfer-in
What is your greatest concern about attending college?
How did you hear about the Umoja Learning Community?
If counselor referral, please provide name of the counselor
Do you have any skills, interest or talents you might consider sharing with other students in the community? If so, what are they?
If mentoring is available, please indicate preference
Male
Female
Educational Goal
Earn AA/AS Degree only
Transfer without AA/AS Degree
Transfer with AA/AS degree
Earn a Certificate
Other
What types of schools are you interested in transferring to ?
University of California System Institutions
California State University System Institutions
Historically Black Colleges and Universities (HBCU)
Private Institution
Enrollment Status
New to college
Continuing student
Transfer (from another college)
Full time (12 units or more)
Part-time (less than 12 units)
Citizenship Status
U. S. Citizen
Permanent Resident
Other
Financial Aid status
Awarded
Not Awarded
Major and/or career interests?
Are you interested in working in the healthcare profession?
Yes
No
Healthcare encompasses a broad group of health professionals who use scientific principles and evidence-based practice for the diagnosis, evaluation and treatment of acute and chronic diseases; promote disease prevention and wellness for optimum health, and apply administration and management skills to support health care systems in a variety of settings. Allied health care professionals work in health care teams to make the health care system function by providing a range of diagnostic, technical, therapeutic and direct patient care and support services that are critical to the other health professionals they work with and the patients they serve.
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