CareerandCollegePromiseApplicationforAdmission
2015– 2016Academic Year
Applicationswill notbeprocesseduntilall requiredsignatures areobtained andall required documents(testscoresandhigh schooltranscript)havebeenreceived. Submit with verification form.
Are you a: □New CCP Student□ReturningCCP Student
Social Security Number: ______- _____ - ______or R-CCC Student ID# ______
Last Name: ______First Name: ______Middle Name: ______
Mailing Address: ______
City: ______State: ______Zip: ______County: ______
Home Phone#: (______) ______Email Address: ______
Gender: □Male□FemaleDate of Birth (mm/dd/yyyy): ______
Residency:
Are you a North Carolina resident? □Yes□No
Have you lived in North Carolina continuously for the past 12 months? □ Yes□No
If NO, where else have you lived in the past 12 months? ____________
Ethnicity (Please select only one)Race (Please select all that apply)
□Hispanic/Latino□American Indian/Alaska Native □Native Hawaiian/ Pacific Islander
□Non-Hispanic/Latino□Asian□White
□Black/African American□Other
Employment Status: Mark the appropriate box with an X:
□Unemployed - not seeking employment (UN)□Unemployed - seeking employment (US)
□Employed 1 - 10 hours per week (E1)□Employed 11 - 20 hours per week (E2)
□Employed 21-39 hours per week (E3)□Employed 40 or more hours per week (E4)
Enrollment Status (Check one)
□ Never attended any college before (F)□Have attended a college before (T)□Have attended R-CCC before (R)
Year and Semester You Plan to Start:______
Year Semester (fall, spring, summer)
Intended Career & College Promise Pathway Code: ______
Educational Goal at R-CCC (Check only one):
□Obtain Degree, Diploma, or Certificate (GR) □Personal Enrichment (PE)
□Enhance New Employment Skills (EN) □Transfer to another College (TR)
□Enhance Present Employment Skills (EP)□Goal Unknown (GU)
Institution Attended –Complete as Applicable
Current High School Name: ______
School NameCity State
My high school is:□Public □ Charter □Private□HomeSchool
What is your current grade?9101112Expected Graduation Date (mm/yyyy): ______
High School track:___college prep(CP)___general prep (GP)____vocational prep (VP)
Colleges and Other Post Secondary Schools Attended (List All):
College/Post Secondary School NameCity/StateYears Attended (if applicable)
______
______
Emergency Contact Name: ______Relationship: ______
Contact Number: (______) ______
Applicants:Pleaseread, checkthe boxesbelow,thensign anddate.
□I herebycertifythat theinformation Ihavegiven is true to thebestofmyknowledge. I furtherunderstandthatfalsificationorfailuretosupply the correctinformation maybeconsideredgrounds for rejectionor dismissal.
□I authorize arepresentativeof Roanoke-ChowanCommunityCollegetoreleaseinformation regarding myacademicrecord/transcriptincluding attendanceinformation to myparent/guardianandhigh schoolstaff.
ApplicantSignature______Date______
□I give permission for my child to participate in the Career and College Promise program at Roanoke-Chowan Community College and acknowledge courses taken will be listed on the high school and college transcripts.
Parent/Guardian Signature ______Date: ______