This form is open now for next year’s registration (running Sept 2021 – May 2022). Please fill out this form for the person who will be attending class. Complete a separate registration form for each additional person who plans to attend. 1Registrant Ino2Class Registration3Additional Questions4Finalize HiddenItem Number Parent InformationParent's Full Name* First Middle Last Do you have a previous name?* Yes No Previous Name*Please list any first or last names you have formerly used. Mailing Address* Street Address City ZIP Code Email* Enter Email Confirm Email Phone Number*Parent's Date of Birth*You must provide your date of birth (MM/DD/YYYY); it will be used to create your initial PIN for access to your electronic records. Have you ever enrolled at Bellevue College in the past?* Yes No Not Sure Bellevue College Student ID#Please provide your Bellevue College Student ID#. If you do not know your ID# we will look it up using your Date of Birth. Quarter*Select the Quarter you will begin attending Fall 2021 Winter 2022 Spring 2022 What type of Parent Education offering are you interested in?* I am signing up for a Parent Education class (infant/wobbler/toddler/labs) I would like to sign up for Cooperative Preschool I would like to sign up for a Parent Only Class Child InformationChild's Name* First Last Child's Date of Birth*Enter the month and year your child was born (MM/DD/YYYY). Second Child? Add a second child Parents can register up to two children for the SAME class if BOTH meet the age requirement.2nd Child's Name First Last 2nd Child's Date of BirthEnter the month and year your child was born (MM/DD/YYYY). Class Age Range*Select age range based on how old child will be on August 31 of the year when the class begins. Infant/Wobbler (0-15 months)Toddler (13-36 months)Preschooler and Older (3-9 years) 2021-2022 Class RegistrationInfants/Wobblers 7001 (1/21 – 9/21) Campus Infants (Wednesday AM) 7004 (9/19– 8/21) Online Infant/Wobbler/Toddler (Wednesday PM) 7005 (5/20 – 12/20) Campus Wobblers (Thursday AM) Toddlers 7004 (9/19– 8/21) Online Infant/Wobbler/Toddler (Wednesday PM) 7005 (5/20 – 12/20) Campus Young Toddlers (Thursday AM) 7010 (3/19 – 3/20) Mercer Island 1st & 2nd Year Toddlers (Wednesday AM) 7011 (9/19 – 8/20) Mercer Island 1st Year Toddlers (Thursday AM) 7014 (9/18 – 8/19) Eastgate 2nd Year Toddlers (Tuesday AM) 7017 (9/19 – 8/20) North Bellevue 1st Year Toddlers (Tuesday AM) 7023 (9/18 – 8/19) Renton Sunrise 2nd Year Toddlers (Monday AM) 7029 (9/18 – 8/19 Issaquah 2nd Year Toddlers (Monday AM) 7036 (9/18 – 8/19) Alpine 2nd Year Toddlers Co-Op Cooperative Preschools 7036 Alpine 2s Snoqualmie Valley 7046 Mercer Island all ages 7048 Eastgate 3’s and 4’s 7051 Bellevue-Overlake 3’s and 4’s 7052 Alpine 3’s and 4-5’s (3 by 8/31/21) 7057 Renton Sunrise 3’s and 4’s Arts & Science LabsOne Day Unique Classes for 3-9 Year-Olds 7091 (Age 3 by 12/31/21) Bellevue College Campus Creative Development Lab (Tuesday AM or PM) 7093 (Age 2.5-6yrs) Online Art & Science Lab (Saturday PM) 7095 (5-9 years) Discovery Science Lab (Wednesday PM) Parent Only Classes 7096 Positive Discipline (Oct 11-Nov 8) Bellevue College Campus (Monday PM) Additional InformationThis data is used for state reporting and statistical purposes. All information is voluntary and will not affect consideration for admission. Which race do you consider yourself to be? You may choose one or two categories from the following:Bellevue College reaffirms its policy of equal opportunity regardless of race or ethnicity; creed; color; national origin; sex; marital status; sexual orientation; age; religion; genetic information; the presence of any sensory, mental, or physical disability; or veteran status. Please visit www.bellevuecollege.edu/equal/ for more details. African American/Black (872) Alaska Native (015) American Indian (597) Chinese (605) Filipino (608) Japanese (611) Korean (612) Native Hawaiian (653) Vietnamese (619) White (800) Other Asian (621) Other Pacific Islander (681) Other Race (799) What is your ethnicity? Hispanic or Latino/a (717) Not Hispanic or Latino/a (999) Gender Male Female What is Your family status? Single parent with children or dependents Couple with children or dependents Single or married without children or dependents What is your current work status? Full-time homemaker Full-time employment Part-time off campus Part-time on campus Not employed, but seeking employment Not employed, not seeking employment What is the highest level of education you have completed? Less than high school GED Highschool graduate Some post high school, no degree or certificate Certificate Associate Degree Bachelor’s Degree What is your main long-term goal for attending Bellevue College? Taking courses related to current or future work Transfer to a four-year college High school diploma or GED Explore career direction Personal enrichment Are you here this quarter earning credits for a degree or certificate? Yes, a BC transfer degree Yes, a BC occupational degree or certificate Unsure how I will be using these credits No plans for a BC degree or certificate How long do you plan to attend Bellevue College? One quarter Two quarters One year One or two years Long enough to complete a degree I don’t know Finalize your RegistrationSocial Security Number Disclosure*To finalize your registration we will need your Social Security Number (SSN). The college will then assign you a student identification number for future use. To comply with federal laws, we are required to ask for your SSN. We will use your SSN to report Hope Scholarship/Life Time tax credit, to administer state/federal financial aid, to verify enrollment, degree and academic transcript records, and to conduct institutional research. If you do not submit your SSN, you will not be denied access to the college; however, you may be subject to civil penalties (refer to Internal Revenue Service Treasury Regulation 1.6050S-1(e)(4) for more information). Pursuant to state law (RCW 28B.10.042) and federal law (Family Educational Rights and Privacy Act), the college will protect your SSN from unauthorized use and/or disclosure. I understand that my registration may not be finalized until I provide my social security number to Bellevue College.PhoneThis field is for validation purposes and should be left unchanged. Last Updated April 26, 2021