Meeting of The

CAREER COLLEGE Application for Admission

2018-2020

PART 1. PATHWAY PREFERENCE

Please check one pathway listed below:

□ I am applying for the Animal Care Assistant pathway

□ I am applying for the Automotive Assistant pathway

□ I am applying for the Health & Public Services Assistant pathway

□ I am applying for the Nursery/ Greenhouse Assistant pathway

PART 2. STUDENT INFORMATION

NAME: [print] ______

ADDRESS: ______

______

PHONE: (___) ______

CELL PHONE: (____) ______

EMAIL ADDRESS: ______

SOCIAL SECURITY NUMBER: ______-______-______

DATE OF BIRTH: ______AGE: ______month day year

GENDER: □ male □ female

WILL YOU BE AT LEAST 18 YEARS OLD BY THE PROGRAM STARTING DATE? □ Yes □ No

RACE: □ White □ African-American □ Native American □ Hispanic □ Asian □ Other

DO YOU HAVE A DRIVER’S LICENSE? □ YES □ NO

HAVE YOU COMPLETED HIGH SCHOOL? Read all the answers and then check the most correct answer.

□ Yes, I received my diploma in (month & year) ______.

□ Yes, Ireceived my “Graduation Certificate” (formerlyCertificate of Achievement) in (month & year) ______.

□ No. My highest grade completed was grade ______in (month & year) ______.

WHAT WAS THE LAST HIGH SCHOOL YOU ATTENDED?

School Name: ______

City: ______State:______

PART 3. STUDENT RECORDS

TRANSCRIPTS: Students are responsible for contacting their previous high school and requesting a sealed, official copy of their high school transcript.
DISABILITY SERVICES: Students who require disability services or reasonable accommodations must identify themselves as having a disability and provide current diagnostic documentation to the Disability Services Office located in the Student Success Center (room 233). Please contact Monica Isbell, Coordinator of Disability Services for more information (336) 506-4130 or email at

PART 4. FINANCIAL ASSISTANCE

Financial Assistance may be available for the cost of Career College. Applicants must submit a written statement explaining his/her financial needs. This statement must be submitted with the application packet.

PART 5. SCHOOL/AGENCY REFERENCES

A Career College Reference Form is to be completed by three individuals or agencies (examples: teacher, Job Coach, counselor, employer or supervisor). Each representative will complete the Reference Form, seal it, and give it to the student to include with this Application for Admission. Each reference must be someone familiar with the student’s skills and work habits.

PART 6. COMMUNITY SUPPORTS OR SERVICES

Listed below is a list of community supports or services. Please check the ones that apply to you:

□ Division of Vocational Rehabilitation (VR)

□ Managed Care Organizations (Cardinal Innovations, Sandhills, Alliance)

□ Mental Health (RHA, Trinity Behavioral Health, Carolina Behavioral Care (CBC), Cardinal Innovations)

□Social Security Disability Insurance

□□ Supplemental Security Income

□ Other: ______

PART 7. CURRENT EMPLOYMENT INFORMATION

[Leave this section blank if currently unemployed]

EMPLOYER: ______
Please check one that apply to you:
□ VOLUNTEER WORK □ PAID EMPLOYMENT
DIRECT SUPERVISOR: ______
WORK PHONE: (_____)______
WORK DAYS HOURS:______
RATE OF PAY:______
NUMBER OF HOURS: ______

PART 8. PERSON TO CONTACT IN CASE OFAN EMERGENCY

NAME:______
RELATIONSHIP:______
HOME PHONE: ______
WORK PHONE:______
CELL PHONE:_________
MAY WE DISCUSS YOUR INFORMATIONWITH THIS PERSON?
□Yes(if yes, put your initials here :) ______
□ No

APPLICANT’S SIGNATURE

[Please read and sign below]

By completing and submitting this application, I agree to the policies and procedures of Alamance Community College. I understand my failure to provide complete, accurate and truthful information on this application may be grounds for refusal of admission at Alamance Community College.

Student’s Signature: ______Date:______

Career College Application

Revised 11/28/17