College

Career Pathways

2016-2017 CCP Enrollment Form

PREP

Capital Community College 950 Main Street Hartford, CT 06103

[email protected] 860-906-5000 ext. 6420

___________________________________________________________________________________________________ Today’s Date

Soc. Sec. Number *

Date of Birth *

___________________________________________________________________________________________________ Last Name * First Name * Middle ______________________________________________________________________________________________________________ Address * Email Address*

__________________________________________________________________________________ City *

State *

___________________________________

Zip Code *

_____________________________________________

Telephone Home *

Cell number *

Name of High School *: ____________________________________________ Grad. Year *: ______________________

Sex *:  Male  Female

Race * :  White  Asian  Black/African American  American Indian or Alaskan Native  Native Hawaiian or Other Pacific Islander  Choose not to respond

Ethnicity *:  Hispanic/Latino  Non-Hispanic/Non-Latino

Citizenship *:  U.S. Citizen  Student Visa  Permanent Resident  Other Career Pathway *: WHPS Pathway Offerings  Communication Media (GZ03)  Criminal Justice (GZ12)  Architecture (GZ02)  Early Childhood Education (GZ05) (Childhood Careers)  Accounting (GZ06) (Accounting & Financial Literacy)  Computer Information Systems (GZ11) (Web Design)  Health Information Management (GZ08)  Construction Management (GZ02)

Parent/Guardian Printed Name:_______________________________________________________________________

Address (if different):________________________________________________________________________________ Non-Discrimination: CCC does not discriminate on the basis of race, color, national origin, ancestry, religious creed, age, gender, marital status, past or present history of mental disorder, retardation, or physical handicap, prior conviction of a crime, sexual orientation, or political affiliations in admitting students to its programs or in administering its educational policies, loans/scholarship programs, athletics, and other institutional administrative programs or activities generally made available to students at the college. The undersigned agrees that information on this application is true and accurate and understands it will be kept confidential in accordance with the provisions of the privacy act. Misleading or false information may result in disqualification or dismissal. Applicant’s Signature:_________________________________________________ Date:______________

Parent/Guardian Signature *:_______________________________________ _____________ Date:______________ This application will not be processed without parent/guardian signature

* All information must be complete

IMPORTANT DATES FOR HIGH SCHOOL/STUDENT/GUARDIAN FULL YEAR COURSES: Sept 15th – Enrollment applications due to Capital CC Oct. 31st – Final Day to Drop (after this date, students can Withdraw but future financial aid may be impacted) Nov. 1st – April 30th – Withdrawal period (after this period, students will receive the grade earned which may impact college GPA and future financial aid)

HALF YEAR COURSES: June 1st – Enrollment applications due to Capital CC (High School may set an earlier due date) Feb. 1st – Final Day to Drop (after this date, students can Withdraw but future financial aid may be impacted) Feb. 2nd – April 30th – Withdrawal period (after this period, students will receive the grade earned which may impact college GPA and future financial aid)

If these due dates are not met, students will not be eligible to receive college credit.