Reactivation Form

Student Information

First Name

Middle Initial

Last Name

Former/Maiden Name

Primary Contact Phone

Secondary Contact Phone

Birth Date

SSN or Zane State Id

Email Address

Re-Enter Email Address

If male, aged 18 to 26, please provide your Selective Service Number. To look up your number go to sss.gov

Selective Service Number

Current Address

Address Line 1

County

Address Line 2

City

Country

Zip Code

Returning Information

Return Year

Have you resided in Ohio for the immediate past 12 months?

Yes No

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Demographic Information

Your response in this section is voluntary. Information will not be used in a discriminatory manner and will remain confidential as to the individual, but may be used in general submission data.

Are you Hispanic?

Yes No

Please select one or more of the following categories to describe yourself:

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

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Previous Education

Are you a graduate of Zane State College

Yes No

List all colleges attended with most recent first:

Name of College

City/State

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Emergency Contact Information

In the event of emergency, notify:

Last Name

First Name

Phone Number

Release of Information

Zane State College has permission to release my name, address, telephone listing, college major, dates of attendance, degrees and awards received (including dean’s list) and most recent previous education agency or institution attended to news media or other appropriate agencies.

YesNo

Initial here to acknowledge

I hereby certify that all statements on this form are correct and understand that I may be required to provide documentation at some future date to substantiate my claim and that any misrepresentation of this data may result in the cancellation of my enrollment or registration status and is considered a breach of academic honesty.

AgreeDisagree

Initial here to acknowledge