Imperial Valley College Correctional Academy Fall Semester 2022

Correctional Academy Application

Page 1 of 14 - Applicant Information

7%
Name Name Title First Middle Last Suffix
Student G# (do not enter G, start with 00)
Social Security Number
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone # Cell Phone # - ### - ### ####
Work or Other # Work or Other # - ### - ### ####
Email
Date of Birth Date of Birth / MM / DD YYYY
Age
Ethnic & Racial Category

Ethnic Category
*Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to "Hispanic or Latino."

*Not Hispanic or Latino

Racial Categories
*American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

*Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

*Black or African American A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American."

*Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

*White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Choose one or more Racial Identities (regardless of ethnicity):

Choose one or more Racial Identities (regardless of ethnicity): Hispanic/Latino Not Hispanic/Latino

Please see definitions above.
Choose one or more Racial Identities (regardless of ethnicity):

Choose one or more Racial Identities (regardless of ethnicity): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Two or more of the selection above

Please see definitions above.
Alias or other names known as Alias or other names known as Title First Middle Last Suffix
Are You A U.S. Citizen

Are You A U.S. Citizen Yes No
Do you have any scars or tattoos?

Do you have any scars or tattoos? Yes No
If yes, please describe in detail.
Emergency contact person name Emergency contact person name First Last
Emergency contact person phone number Emergency contact person phone number - ### - ### ####
Emergency contact person relationship to you
Please enter your belt size for the uniform
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

Imperial Valley College Correctional Academy Fall Semester 2022

Imperial Valley College Correctional Academy Fall Semester 2022

Page 1 of 14 - Applicant Information

Ethnic & Racial Category