Transient Reactivation Form

Complete and submit this form if you wish to take classes as a Transient (Guest) student at Rhodes State College. This form should only be completed by individuals who have received grades from Rhodes State College and/or Lima Technical College in the past.

Planned Term to Enroll	Select an item Summer 2020 Fall 2020	*
Student ID (begins with an "R" followed by a series of numbers) If you do not know this number...leave this blank.
Date of Birth - mm/dd/yy		*
Gender	Female Male
First Name		*
Last Name		*
Middle Initial		*
Maiden/Previous Name If Applicable
Street Address		*
City		*
State		*
Zip Code		*
Phone Number		*
Email Address		*
Will you be using Military Educational Benefits	Yes No	*
Are you currently serving in the U.S. Armed Forces or are you a veteran?	Yes No	*
Are you a U.S. Citizen?	Select an item Yes No	*
If no, please select one of the following?	Select an item Permanent Resident Non-Immigrant Visa Holder
Have you resided in Ohio for the immediate past 12 months?	Select an item Yes No	*
If no, in which state are you a legal resident?
Rhodes State has permission to release my name, address, telephone number, college major, participation in officially recognized activities and sports, dates of attendance, degrees and awards received (including Dean's list) and most recent previous educational agency or institution attended to news media, car pool lists, or other appropriate agencies.	Select an item Yes No	*
Last term you received grades from Rhodes or LTC (If you can recall)
If male, aged 18-26, have you registered for the Selective Service?	Select an item Yes No N/A	*
If yes, enter your selective service number.
What is the name of your home College/University
Full Name of Emergency Contact		*
Emergency Contact's relationship to you		*
Emergency Contact's Phone Number		*
By typing my full name in this box, I confirm that I am the student named above and that information is correct on this form		*