Get documents about "BLINN COLLEGE APPLICATION FOR ADMISSION Texas
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BLINN COLLEGE APPLICATION FOR ADMISSION
Texas Department of Criminal Justice TDCJ#____________
INSTRUCTIONS: Please print or type and be sure to answer each question. Please submit this application to the campus you plan to
attend. All documents submitted to the College become part of the official files and cannot be returned.
Social Security Number: When do you plan to enter Blinn College? (Select only one and indicate year.)
- -
________________________ Fall 2008___ Spring 2009___ Summer I 2009___ Summer II 2009___ Other_________________
Which campus(es) do you plan to attend: ___Brenham ___Bryan ___Other (Identify)___________________________________
Have you previously applied at Blinn? ___YES ___NO When?__________ Previously attended? ___YES ___NO When?___________
Name: Give full legal name as it appears on all legal documents
Last_______________________________________ First______________________________ Middle_________________________
Indicate any other names under which your academic records may be -
found.
Last_______________________________________ First______________________________ Middle_________________________
Permanent Mailing Address Local Mailing Address
_________________________________________________________ _________________________________________________________
Street Address or P.O. Box Street Address or P.O. Box
_________________________________________________________ _________________________________________________________
City State Zip Code County City State Zip Code County
Permanent Phone Number (_______)______________________
Local Phone Number (_______)___________________________
Email Address:________________________________________
Ethnic ___1. American Caucasian (White) ___5. American Indian/Alaskan Native Check One: Sex:
Origin ___2. American Black ___6. International Student ___1. U.S. Citizen ___ Male Date of Birth: _____/_____/_____
___3. American Hispanic ___7. Other ___2. Naturalized Citizen ___ Female
___4. Asian or Pacific Islander ___3. Resident Alien
___4. International Place of Birth:
High Name of City State or Year HS
School HS Country Graduation
Check any of the following that apply:
______ 1. Graduated from a state accredited high school.
______ 2. Completed GED - Date certificate awarded ____________________. Copy of official scores are required.
______ 3. Dual Credit or Early Admissions, still in high school and not taking more than two college courses.
______ 4. Individual Approval. Requires approval letter from the Registrar.
______ 5. Non-Degree/Non-Certificate student. You are taking course(s) for enrichment only.
______ 6. International Student. Contact Admissions and Records Office for entrance requirements and procedures.
______ 7. Re-entry Student. You have attended Blinn College and have not attended another college since leaving.
______ 8. Transfer or Co-enrolled Student. You are transferring to Blinn College or you are attending another university/college during
the same semester.
______ 9. Home School Graduate. You have graduated from a certified home school program.
Is this your first time in college? ___YES ___NO If yes, go to the THEA Section.
List ALL colleges or universities you have attended including Blinn College. List most recent first. Failure to disclose colleges may
result in non-admission. If you have attended a college or university, a transcript from each institution attended will be required.
College or University Name Location First Semester/Year Last Semester/Year
Total semester hours completed at all colleges/universities: ___ 0 to 29 hours ___ 30 to 71 hours ___ 72 hours and up.
Are you presently on disciplinary suspension/probation? ___YES ___NO If Yes, specify______________________________________
THEA Status: ___I have taken the THEA Test. ___I am exempt from the THEA Test. ___I have not taken THEA Test.
Official THEA scores or proof of exemption must be provided prior to admissions.
Completion of this application serves as authorization to access your scores. Upon request, the college will provide the student a copy
of the scores. The student has the right to challenge the scores if he/she believes they are not correct.
What is your intended major?________________________ Do you plan to earn a degree or certificate in this major? ___YES ___NO
Are you planning to seek a teaching certificate in addition to your degree? ___YES ___NO
Emergency contact person (optional): Relationship to you: ( ) Parent ( ) Spouse ( ) Other
Name: __________________________________ Address___________________________________________
Home phone: ( )______________________ City ______________________________________________
Day phone: ( )_______________________ State_________________________ Zip_________________
Have you been involved in any of the following while in high school? (Check any of the following that apply)
Limited English Proficiency Class____ Future Teacher Club or Class____
Honors Program____ Tech-Prep Program____ Agricultural Science____ 4H/FFA____
Please indicate the highest level of your parents’ or court appointed legal guardian’s educational background:
Father/Legal Guardian: Not a high school graduate____ High School diploma or GED____
Some College____ Associate Degree____ Bachelor’s Degree____ Graduate/Professional Degree____
Mother/Legal Guardian: Not a high school graduate____ High School diploma or GED____
Some College____ Associate Degree____ Bachelor’s Degree____ Graduate/Professional Degree____
PART I. Certification of Residency. All students must complete this section.
I understand that officials of my college/university will use the information submitted on this form to determine my status for residence
eligibility. I authorize the college/university to verify the information I have provided. I certify that the information on this application is
complete and correct and I understand that the submission of false information is grounds for rejection of my application, withdrawal of
any offer of acceptance, cancellation of enrollment, and/or appropriate disciplinary action.
Signature: __________________________________________________ Date: ______________________________
STATEMENT OF EQUAL EDUCATIONAL OPPORTUNITY
Blinn College seeks to provide equal education without regard to race, color, creed, religion, sex, disabling condition, age, national origin,
or veteran’s status. This policy extends to all programs and activities supported by the college.
IMPORTANT INFORMATION ABOUT BACTERIAL MENINGITIS
This information is being provided to all new college students in the state of Texas. Bacterial Meningitis is a serious, potentially
deadly disease that can progress extremely fast - so take utmost caution. It is an inflammation of the membranes that surround the brain
and spinal cord. The bacteria that causes meningitis can also infect the blood. This disease strikes about 3,000 Americans each year,
including 100-125 on college campuses, leading to 5-15 deaths among college students every year. There is a treatment, but those who
survive may develop severe health problems and disabilities.
What are the Symptoms:
High fever Severe headaches
Rash or purple patches on skin Vomiting
Light sensitivity Stiff neck
Confusion and sleepiness Nausea
Lethargy Seizures
There may be a rash of tiny, red-purple spots caused by bleeding under the skin. These can occur anywhere on the body. The more
symptoms, the higher the risk, so when these symptoms appear seek immediate medical attention.
How is Bacterial Meningitis Diagnosed?
• Diagnosis is made by a medical provider and is usually based on a combination of clinical symptoms and laboratory results from
spinal fluid and blood tests.
• Early diagnosis and treatment can greatly improve the likelihood of recovery.
How is the Disease Transmitted?
The disease is transmitted when people exchange saliva (such as kissing, or by sharing drinking containers, utensils, cigarettes,
toothbrushes, etc.) or come in contact with respiratory or throat secretions.
How Do You Increase Your Risk of Getting Bacterial Meningitis?
• Exposure to saliva by sharing cigarettes, water bottles, eating utensils, food, kissing, etc.
• Living in close conditions (such as sharing a room/suite in a dorm or group home).
What are the Possible Consequences of the Disease?
• Death (in 8 to 24 hours from perfectly well to dead)
• Permanent brain damage
• Kidney failure
• Learning disability
• Hearing loss, blindness
• Limb damage (fingers, toes, arms, legs) that requires amputation
• Gangrene
• Coma
• Convulsions
Can the Disease be Treated?
• Antibiotic treatment, if received early, can save lives and chances of recovery are increased. However, permanent disability or
death can still occur.
• Vaccinations are available and should be considered for:
• Those living in close quarters
• College students 25 years old or younger
• Vaccinations are effective against 4 of the 5 most common bacterial types that cause 70% of the disease in the U.S. (but does
not protect against all types of meningitis).
• Vaccinations take 7-10 days to become effective, with protection lasting 3-5 years.
• The cost of vaccine varies, so check with your health care provider.
• Vaccination is very safe - most common side effects are redness and minor pain at injection site for up to two days.
How Can I Find Out More Information?
• Contact your own health care provider.
• Contact web sites: www.cdc.gov/ncidod/dbmd/diseaseinfo; www.acha.org
I acknowledge that Blinn College has provided me with and I have read and understand this information.
________________________________________________ ________________________________________________
Signature Social Security Number or Student ID Number
2.28.07
