Legal Name:
Last: 
First: 
M.I.:  
Maiden Name (if Applicable):
Valid E-Mail Address:
Verify E-Mail Address:

Social Security Number:

Date of Birth:   Example: 04/01/1981

Permanent Address:
Apt. Number, PO Box, or Street Address:
City:
County, if a Kansas resident:
State: ZIP CODE:

Country, if other than U.S.A.:

Mailing Address of Residence: (Enter only if it differs from your permanent address above.)
Street Address:
City:
County, if a Kansas resident:
State: ZIP CODE:

Country, if other than U.S.A.:

Kansas Resident?: YES /  NO

Home Telephone Number:
Work Telephone Number: Ext.:

Have you previously attended CCCC?: YES / NO

If YES, date attended: (Yr.) From To

If you have an Academic Advisor at CCCC, please identify him/her.
Select your assigned Academic Adviser from this list. Acree, Jenny Bryant, Krista Elwood, Tena Farha, Shelly Ford, Everett Kristen Cervantes Hartman, Jennifer Jones, Nick Leif, Todd Dr. McGuire, William Monzon, Deb Pounds, Kevin Robison, Joan Schmitz, Ted Thompson, Scott Whisler, Beth Zabokrtsky, Jennifer

Do you want Academic Advisement assistance?: YES /  NO

Is this your first Internet-based Class?: YES /  NO

If this is not your first CLOUD Online class, enter your current Blackboard System account info. Username: Password:

Anticipated Method of Payment?: Select one of the following Federal Financial Aid Self-pay, personal funds - credit card, check or cash FACTS Payment Plan Self-pay, employer tuition assistance V.A. Vocational Rehab State Vocational Rehab Regular G.I. Bill Military Tuition Assistance NEKAP for Child Care Program Students Project TEACH for Child Care Program Students