Adult Basic Skills - Enrollment Form

UCC Adult Basic Skills

Enrollment Form

Thank you for your interest in Adult Basic Skills at UCC!

Please fill out the form below:

Starting Term

Program of Interest

First Name

Middle Initial

Last Name

Phone

Cell Phone

Mailing Address

City

State

Zip Code

Date of Birth (mm/dd/yyyy)

Social Security Number (optional)

Age

Gender

Race / Ethnic Background

Highest Grade Completed

Last School Attended

Highest Diploma / Degree Earned

How are you paying for classes?

Are you a U.S. citizen?

Would you like to be on our email and texting lists?

Employee Website (The Nest) | Hawk Squawk eNewsletter | Alumni Membership | Complaints & Concerns | COVID-19 Information

© 2022 Umpqua Community College, 1140 Umpqua College Rd., Roseburg, OR 97470
Phone: 541-440-4600 | Toll Free: 800-820-5161 | Oregon Relay TTY: 711

UCC Non-Discrimination Statement.
UCC is an equal opportunity employer and educator.
Umpqua Community College is accredited by the Northwest Commission on Colleges and Universities.

Main Menu (Mobile)

UCC Adult Basic Skills

Enrollment Form