as Aquinas C m o ho lleg T e California - 1971 Memorandum To: Class of 2022 From: Jon Daly, Director of Admissions Re: Registration forms Greetings! Please complete and return the enclosed registration forms as soon as possible, and no later than May 1. Please also take care to complete each part of these forms. If a question on a form does not apply to you, please mark “N/A” in the space provided. In addition to these completed forms, the College also requires that you provide the following documents to com- plete your registration: • Immunization records • Copy of health insurance card • Final high school transcript (with signature and date of graduation) Registration forms The completed and signed forms should be mailed to: Thomas Aquinas College, Attn. Admissions Office 10,000 Ojai Rd, Santa Paula, CA 93060 Freshman deposit If you have not already made your $250 freshman deposit, you can do so online at www.thomasaquinas.edu/freshman-deposit. Free t-shirt! We would like to send you your own “Class of 2022” t-shirt! Please visit www.thomasaquinas.edu/freshmantshirt and let us know your preferred size. Please do not hesitate to call or email the Admissions Office with any questions. You can reach us at 800-634-9797 or [email protected]. hTomas Aquinas Coll eeg Class of 2022 California - 1971 Freshman Registration Date______________ Please Print Name ___________________________________________________________________________________ Last name First name Middle name Birthplace _______________________________Birthdate ________Social Security Number __________________ Home address ______________________________________________________________________________ Home phone ____________________________________________Student cell phone ______________________ Email ____________________________________________________________________________________ Parents who have attended Thomas Aquinas College? q No q Yes Name(s): __________________________________ Siblings who have attended Thomas Aquinas College? q No q Yes Name(s): __________________________________ Relatives who have attended Thomas Aquinas College? q No q Yes Name(s): __________________________________ To which printed or online publications does your family subscribe? (optional). __________________________________ ________________________________________________________________________________________ Schools Attended Final Transcript Last high school _____________________________Location ___________Grad. year ________q Sent q Will Send College __________________________________Dates ______________Degree(s) _________q Sent q Will Send College __________________________________Dates ______________Degree(s) _________q Sent q Will Send Will you be taking any classes this summer? q Yes q No q Unsure | Where? _________________________________ Family Information Father’s name q Dr. q Mr. q Other ______________________________________________________________ First name Middle name Last name Address q Same as student’s ____________________________________________________________________ Phone ________________________Mobile __________________Email_______________________________ Employer ______________________________________________Phone ______________________________ Address __________________________________________________________________________________ Mother’s name q Dr. q Mrs. q Ms. q Other _______________________________________________________ First name Middle name Last name Address q Same as student’s ____________________________________________________________________ Phone ________________________Mobile __________________Email_______________________________ Employer ______________________________________________Phone ______________________________ Address __________________________________________________________________________________ Guardian’s name (if different than parents) q Dr. q Mr. q Mrs. q Ms. q Other ________________________________ Address q Same as student’s ____________________________________________________________________ Phone ________________________Mobile __________________Email_______________________________ Employer ______________________________________________Phone ______________________________ Address __________________________________________________________________________________ Siblings (names and ages): ______________________________________________________________________ ________________________________________________________________________________________ admissions/dean hTomas Aquinas Coll eeg Freshman Registration • Class of 2022 California - 1971 Previous Work Experience Name ______________________________ • This form will help our office make work assignments for students whose financial aid from the College includes a Service Scholarship (“work-study”). • Please check “work” column in those boxes to indicate work you have done in that area. If you have had classes or instruction in any of these fields, please indicate this by checking the “class” box. If you commonly do this type of work at home, then check the “home” box. #1 work class home work class home Automotive maintenance _______________________ House cleaning ______________________________ Auto repair/mechanic work ______________________ Driver/courier ______________________________ Library assistant _____________________________ Calligraphy _________________________________ Filing _____________________________________ Drawing/art ________________________________ Receptionist duties ___________________________ Graphic design ______________________________ Telephone _________________________________ Photography ________________________________ Accounting/Bookeeping ________________________ Audio visual ________________________________ Typing ____________________________________ Data entry _________________________________ General yard maintenance _______________________ Computer networking _________________________ Landscaping ________________________________ Web development Nursery/gardening ___________________________ Computer programming ________________________ Mowing ___________________________________ Postage machine operation ______________________ Sprinkler system repair/installation _________________ Retail sales _________________________________ Janitorial/maintenance _________________________ Public relations ______________________________ Carpentry __________________________________ Construction _______________________________ Barista ____________________________________ House painting ______________________________ Food-counter service __________________________ HVAC ____________________________________ Server ____________________________________ Electrical __________________________________ Cook/food prep _____________________________ Dishwashing ________________________________ Other ____________________________________ Baking ____________________________________ _________________________________________ Catering ___________________________________ _________________________________________ #2 Employer name, job title, and length of service ________________________________________________________________________________________ ________________________________________________________________________________________ #3 Please note any other factors that may be helpful to the business office as they assign students to particular departments. ________________________________________________________________________________________ #4 Preferences • Please rank your top three job preferences, #1 being most desired. Bookstore _____________ Carpentry ____________ Computer Maintenance ___ Courier/Driver __________ Gardening ____________ Janitorial Work _________ Kitchen ______________ Lab Assistant ____________ Library ______________ Mechanical Work _______ Office Work ___________ Coffee Shop _____________ business hTomas Aquinas Coll eeg Freshman Registration • Class of 2022 California - 1971 Roommate Selection Questionnaire Name ______________________________ With your happiness and comfort in mind, please answer the following questions about yourself. The information will aid the Col- lege in assigning dormitory rooms and roommates. If you need additional space, please write on the back of this page. Age at enrollment: _______ Height: ______________ I would prefer to room with someone ❏ older ❏ younger ❏ same age ❏ doesn’t matter Comments: _______________________________________________________________________________ I expect to stay up until about ❏ 9:00 pm–10:00 pm ❏ 11:00 pm ❏ 12:00 am or later Comments: _______________________________________________________________________________ I expect to rise at about ❏ 6:00 am ❏ 7:00 am ❏ 8:00 am or later Comments: _______________________________________________________________________________ I am a ❏ heavy sleeper ❏ medium sleeper ❏ light sleeper I ❏ snore ❏ do not snore I would classify the appearance of my room as ❏ meticulous ❏ neat ❏ relaxed ❏ very casual ❏ slovenly Comments: _______________________________________________________________________________ I am ❏ outgoing and talkative ❏ reserved and quiet ❏ somewhere in between Comments: _______________________________________________________________________________ I like music playing in my room: ❏ most of the time ❏ often ❏ rarely My musical preference is: ❏ Classical ❏ Folk ❏ Jazz ❏ Rock ❏ Country Comments: _______________________________________________________________________________ I ❏ never smoke ❏ smoke sometimes ❏ smoke regularly Do you mind being around people who smoke? ❏ yes ❏ no Please note any sports, hobbies, or interests: __________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Please note any other factors or concerns which may influence your roommate assignment: ___________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ admission hTomas Aquinas Coll eeg Freshman Registration • Class of 2022 California - 1971 Emergency Information and Health Data Name ______________________________ Birthdate ____________________________ Thomas Aquinas College refers students with illness/injuries to local facilities for medical care and/or hospitalization. Your insurance should provide coverage for emergencies. Please attach a copy of both sides of your insurance card to this page. ❏ Insurance card attached ❏ Unavailable If unavailable, please note reason: _________________________________________________________________ Emergency Contact Information: Mother’s name ________________________________Cell ___________________Other _________________ Father’s name _________________________________Cell ___________________Other _________________ Other name/relationship __________________________Cell ___________________Other _________________ Physical activity restrictions (please be specific): _______________________________________________________ Medications you are now taking: __________________________________________________________________ Allergies to drugs, food, or latex: __________________________________________________________________ Recent surgeries or medical problems: ______________________________________________________________ Name of your physician: ____________________________________Phone ______________________________ Please attach available immunization records to this page. ❏ Immunization records attached Thomas Aquinas College requires proof of immunity to the following: • Measles • Mumps • Rubella • Polio • Tdap (tetanus, diptheria, pertussis) • Meningococcal Meningitis (one dose on or after 16th birthday) • Varicella (chicken pox) If not vaccinated, please note approximate date of illness:________________________________ Exemption: ❏ I hereby request exemption from the below immunizations because some immunizations are contrary to my beliefs. I am aware of the symptoms and consequences of these diseases and should I develop any one of these, I understand it may affect my ability to continue studies at the College and accept the responsibility to obtain medical help immediately. Immunizations from which requesting exemption: ______________________________________________________ Exemption: ❏ I hereby request exemption from the below immunizations for medical reasons (please attach physician’s note). I am aware of the symptoms and consequences of these diseases and should I develop any one of these, I understand it may affect my ability to continue studies at the College and accept the responsibility to obtain medical help immediately. Immunizations from which requesting exemption: ______________________________________________________ If requesting exemption, signature(s) are required: Date _____________ Student signature __________________________________________________________ Date _____________ Parent signature** __________________________________________________________ **If student is under 18 years of age, parent or guardian must also sign. health service hTomas Aquinas Coll eeg Freshman Registration • Class of 2022 California - 1971 Name: ______________________________ California Required Meningococcal Disease Awareness Disclosure Meningococcal disease is a serious illness caused by bacteria that can infect the blood or areas around the brain and spinal cord. Infection can lead to brain damage, disability, and rapid death. Meningitis is the most common form of meningococcal disease. Common symptoms of meningitis include stiff neck, headache, and high fever. The meningococcal conjugate vaccine is your best defense at preventing several types of meningococcal disease. A booster dose of the vaccine is now recommended at age 16 or older. If you were vaccinated before age 16, you need an additional dose before enter- ing college. Supplemental information How many people get the disease? Meningococcal disease is a rare but serious disease. An estimated 1,000 people get meningococcal disease each year in the U.S., with 130 to 200 of them in California. After infancy, older adolescents and young adults have the highest rate of meningococcal disease. College freshmen living in dorms are particularly at risk. How serious is it? Even if treated, 10–12% of people who get meningococcal disease will die from it. Of the survivors, 11–19% lose their arms or legs, become deaf or brain damaged, or suffer other complications. How are meningococcal bacteria spread? The bacteria are spread from person to person through air droplets. Close contact such as kissing, coughing, smoking, and living in crowded conditions (like dorms) can increase your risk of getting the disease. Overall, 5–10% of the U.S. population has the menin- gococcal bacteria in their throat, but only a few of them get sick. No one knows why some people get sick and others don’t. How can I protect myself? You can protect yourself by: • not sharing items that have touched someone else’s mouth, such as cups, bottles, cigarettes, lip balm, and eating utensils; • not smoking; and • getting the meningococcal conjugate vaccine. The Centers for Disease Control and Prevention (CDC) recommends one dose at age 11 or 12 and a booster dose at age 16. If you missed your vaccination after turning 16, get it now. How effective are the vaccines? Meningococcal vaccines are at least 85% effective at preventing 4 of the 5 most common forms of meningococcal disease. Ask your health care provider about the benefits and risks of meningococcal vaccines. Source: State of California • Health and Human Services Agency ❏ I have reviewed and understand the above information. Date _____________ Student signature __________________________________________________________ Date _____________ Parent signature** __________________________________________________________ **If student is under 18 years of age, parent or guardian must also sign health service hTomas Aquinas Coll eeg Freshman Registration • Class of 2022 California - 1971 Health History • Student Section - 1 Name _________________________________________________________________ Date _____________ ❏ Male ❏ Female Birthdate _______Home phone _____________________ Cell phone ___________________ Home address ______________________________________________________________________________ Please list any current treatments (injections, physiotherapy, medication, etc.) ___________________________________ ________________________________________________________________________________________ Have you ever had: ❏ ADD/ADHD ❏ Depression medication ❏ Mononucleosis ❏ Alcoholism/Drug addiction ❏ Diabetes ❏ Multiple Sclerosis ❏ Anemia ❏ Emotional illness ❏ Pneumonia ❏ Anorexia ❏ Epilepsy ❏ Poliomyelitis ❏ Anxiety ❏ Head injury ❏ Rheumatic fever ❏ Asthma ❏ Hearing loss ❏ Sleep disorder/Insomnia ❏ Blood clotting disorders ❏ Heart disease ❏ Thyroid disease ❏ Bruising disorders ❏ Hepatitis ❏ Tuberculosis ❏ Bulimia ❏ Hypertension ❏ Tumor/Cancer ❏ Chicken Pox ❏ Kidney disease ❏ Typhoid fever Approximate Date_________ ❏ Malaria ❏ Close association w/tuberculosis ❏ Colitis ❏ Meningitis Other: _______________________ ❏ Depression ❏ Migraines/headaches ____________________________ Please check yes or no to the following: General Yes No Emotional Yes No Female Only Yes No recent weight change ❏ ❏ under care of psychiatrist ❏ ❏ vaginal discharge ❏ ❏ amount +/- _______ under care of psychologist ❏ ❏ lumps in breast ❏ ❏ unusual fatigue ❏ ❏ ever had psychiatric care ❏ ❏ menstrual problems: speech impediment ❏ ❏ ever hospitalized for irregularity ❏ ❏ emotional problems ❏ ❏ interferes with work ❏ ❏ Allergies ever medicated for emotional problems ❏ ❏ Male Only medications ❏ ❏ specify___________ penile discharge ❏ ❏ shots ❏ ❏ hernia ❏ ❏ specify___________ undescended testicle ❏ ❏ foods ❏ ❏ swelling of testicle ❏ ❏ specify___________ plants, animals, etc. ❏ ❏ specify___________ health service hTomas Aquinas Coll eeg Freshman Registration • Class of 2022 California - 1971 Name: ______________________________ Please check yes or no to the following: Eyes Yes No Skin Yes No Heart & Lungs Yes No discharge ❏ ❏ eczema ❏ ❏ chest pain ❏ ❏ blurring ❏ ❏ fungus ❏ ❏ difficulty in breathing ❏ ❏ double vision ❏ ❏ rash ❏ ❏ persistant cough ❏ ❏ injury ❏ ❏ open sores ❏ ❏ impaired vision ❏ ❏ Muscles, Joints & Bones Nose pain ❏ ❏ Ears obstruction ❏ ❏ stiffness ❏ ❏ pain ❏ ❏ sneezing ❏ ❏ swelling ❏ ❏ ringing ❏ ❏ bleeding ❏ ❏ limited motion ❏ ❏ discharge ❏ ❏ varicose veins ❏ ❏ itching ❏ ❏ Nervous System deformity ❏ ❏ perforation of drum ❏ ❏ impaired hearing ❏ ❏ dizziness ❏ ❏ Kidneys convulsions ❏ ❏ unconsciousness ❏ ❏ painful urination ❏ ❏ paralysis ❏ ❏ frequent urination ❏ ❏ numbness ❏ ❏ urinary bleeding ❏ ❏ tremor ❏ ❏ Have you had any serious injuries, illnesses, hospitalizations, or surgeries? ❏ Yes ❏ No If yes, note the date, nature, and resulting complications/limitations. Please use additional sheets if necessary. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ All students admitted to Thomas Aquinas College must meet the academic and personal standards of the College. A student with a disability will not receive accommodations unless he or she requests accommodations. If you have a disability that may require accommodation, please note it below and contact the Director of Admissions at the time you are required to submit this form to discuss your disability and possible reasonable accommodations. Thank you! ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Please note that the College’s Food Service can accomodate some dietary restrictions as noted in the Student Handbook and in the “Campus Living” section of the website, however a note from a doctor is required. Space for this is provided on the Physician Health Form. health service hTomas Aquinas Coll eeg Freshman Registration • Class of 2022 California - 1971 Name: ______________________________ Health History • Student Section - 2 Tuberculosis (TB) Screening Questionnaire Have you ever had close contact with persons known or suspected to have active TB disease? ❏ Yes ❏ No Were you born in one of the countries listed below that have a high incidence of active TB disease? (If yes, please CIRCLE the country, below) ❏ Yes ❏ No Afghanistan Congo Kazakhstan Nepal Somalia Algeria Côte d’Ivoire Kenya Nicaragua South Africa Angola Democratic People’s Kiribati Niger South Sudan Argentina Republic of Korea Kuwait Nigeria Sri Lanka Armenia Democratic Republic of Kyrgyzstan Niue Sudan Azerbaijan the Congo Lao People’s Democratic Pakistan Suriname Bahrain Djibouti Republic Palau Swaziland Bangladesh Dominican Republic Latvia Panama Tajikistan Belarus Ecuador Lesotho Papua New Guinea Thailand Belize El Salvador Liberia Paraguay Timor-Leste Benin Equatorial Guinea Libya Peru Togo Bhutan Eritrea Lithuania Philippines Trinidad and Tobago Bolivia (Plurinational Estonia Madagascar Poland Tunisia State of) Ethiopia Malawi Portugal Turkey Bosnia and Herzegovina Fiji Malaysia Qatar Turkmenistan Botswana Gabon Maldives Republic of Korea Tuvalu Brazil Gambia Mali Republic of Moldova Uganda Brunei Darussalam Georgia Marshall Islands Romania Ukraine Bulgaria Ghana Mauritania Russian Federation United Republic of Burkina Faso Guatemala Mauritius Rwanda Tanzania Burundi Guinea Mexico Saint Vincent and the Uruguay Cabo Verde Guinea-Bissau Micronesia (Federated Grenadines Uzbekistan Cambodia Guyana States of) Sao Tome and Principe Vanuatu Cameroon Haiti Mongolia Senegal Venezuela (Bolivarian Central African Republic Honduras Morocco Serbia Republic of) Chad India Mozambique Seychelles Viet Nam China Indonesia Myanmar Sierra Leone Yemen Colombia Iran (Islamic Republic of) Namibia Singapore Zambia Comoros Iraq Nauru Solomon Islands Zimbabwe Have you had frequent or prolonged visits* to one or more of the countries listed above with a high prevalence of TB disease? ❏ Yes ❏ No If yes, please list countries: ______________________________________________________________________ ________________________________________________________________________________________ *The significance of the travel exposure should be discussed with a health care provider and evaluated. health service hTomas Aquinas Coll eeg Freshman Registration • Class of 2022 California - 1971 Name: ______________________________ Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, and/or homeless shelters)? ❏ Yes ❏ No Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease? ❏ Yes ❏ No Have you ever been a member of any of the following groups that may have an increased incidence of latent M. tuberculosis infec- tion or active TB disease: medically underserved, low-income, or abusing drugs or alcohol? ❏ Yes ❏ No If the answer is YES to any of the above questions, Thomas Aquinas College requires that you receive TB testing as soon as pos- sible but at least prior to the start of the school year. If the answer to all of the above questions is NO, no further testing or action is required. Source: American College Health Association health service