Students-

The Federal Government requires all post-secondary institutions to report various information for students enrolled in their institution. When answering the following questions, be thorough and accurate in your responses. For example, if the question asks for your middle name, enter your middle name, not just the initial.

Your responses are submitted collectively- no personal information is shared with any outside agency other than the student clearinghouse for verification of enrollment, degree history, and student loan processing.

Thank you 

ID Number:

First Name:

Last Name:

Do you have a preferred first name that you wish Mitchell Tech to use?:

Social Security Number:

Changes to your legal name

Make any corrections to your Legal first name:

Make any corrections to your Legal middle name - enter the entire middle name, not just the initial:

Last Name Incorrect

For changes to your last name (misspelling, marriage, divorce, etc) please contact the Registrar's office. You will not be able to change it here.

Please enter information for the person we should contact in case of an emergency.

First Name of Emergency Contact:

Last Name of Emergency Contact:

Emergency Contact Phone Number:

Emergency Contact Relationship to you (parent, grandparent, friend, etc):

Personal E-Mail Address:

Please enter your mobile number or verify the mobile number listed is your number or the best number to reach you:

CURRENT address

Enter your CURRENT address- where you live during the school year.

Current Address (Where you live during the school year):

City:

State:

Zip Code:

Legal Home Permanent Address Information

Legal Home Permanent Address is the address that is considered to be your main residence and not a residence that is being changed on a regular basis while attending college. It is the address that is on your driver’s license and where you would vote prior to attending college. Examples of a Legal Home Permanent Address include but are not limited to: Parent’s or guardian’s home, a home where you live with your spouse and/or child, a home you own or pay a mortgage, a place you have rented for two or more years. Please notify the Center for Student Success if any changes are required.

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Verifying STUDENT military status

Are you a VETERAN (ever served) in the Armed Forces?

Are you a current (ACTIVE) member of the Armed Forces?

Which Branch of the Armed Forces are you serving, or have you served?

Are you a SPOUSE of a veteran or active member of the Armed Forces?

Are you a DEPENDENT of a veteran or active member of the Armed Forces?

Marital Status:

Sex Assigned at Birth:

Does your gender identity match your sex assigned at birth?:

Gender Identity:

What are your lived pronouns?

Hispanic or Not Hispanic

Please select your race from the list below. You have the option to check more than one box.

Did at least one of your parents attend college or technical school beyond high school?

Are you a single parent or are you single and currently pregnant (if female)?

Date of Birth:

Are you unemployed or underemployed and experiencing difficulty obtaining or upgrading employment?

Do you have a parent who is BOTH a member of the armed forces AND is on ACTIVE duty?

Are you homeless and lack a fixed, regular and adequate nighttime residence?

Do you have a LEARNING disability? (ex: dyslexia, dyscalculia, dysgraphia, ADHD, Autism, auditory processing disorder, etc.) 

Do you have a PHYSICAL disability?  (ex: amputation, spinal cord injury, cerebral palsy, etc.) 

Do you have an EMOTIONAL disability?  (ex: anxiety disorders, depression, bipolar disorder, PTSD, OCD, etc.) 

Do you have a HEARING disability? (ex: hearing loss, auditory processing disorder, Tinnitus, Meniere’s disease, etc.) 

Do you have a VISUAL disability? (ex: blindness, low vision, color blindness, macular degeneration, etc.) 

Do you have a SPEECH disability? (ex: stuttering, apraxia, and dysarthria, etc.) 

Neurodiverse is defined as: having a type of brain that is often considered to be different from what is usual.

I identify as neurodiverse: 

I have been informed and fully understand that I am personally responsible for my own health and accident insurance coverage while attending Mitchell Tech.

I understand that the MTC Catalog and Student Handbook can be found online at www.mitchellech.edu.  I further understand that I am responsible for knowing the requirements, policies, and procedures identified in the handbook.