COLLEGECREDIT FOR OFFICE USE ONLY PLUS College for High School Students Fall (August) ____________ Indicate Entry Term/Year Spring (January) ____________ Year Year Legal Name __________________________________________________________________________________________________________ Last FirstMiddle Mailing Address ______________________________________________________________________________________________________ Number and Street Apt. # City Have you lived at your current home address for the last 12 months? If “no”, please list all home addresses within the past 12 months: CITY Yes STATE No Zip County Gender:Male COUNTY FROM MM/DD/YY Female TO MM/DD/YY RESIDENCY INFORMATION STREET State Birth Date _______ /________ /________ Social Security Number - -  (required) Home Phone _________________________________ Cell Phone _________________________________ Email Address ___________________________________________________________________________________________ Citizenship  U.S. Citizen  Non-Citizen  Permanent Resident Country of Birth ______________________________ Country of Citizenship ___________________________ (if not U.S.) Visa Type __________ Alien Reg __________ Issue Date __________ Issue Date __________ Ethnicity  Hispanic or Latino Race  American Indian or Alaska Native [NAM]  Native Hawaiian or Pacific Islander [PAC] Expiration Date __________ Expiration Date __________  Not Hispanic or Latino  White [WHT]  Asian [ASN]  Black or African American [BLK]  Other [OTR] ___________________ Emergency Contact Information Last Name ___________________________________ First Name _________________________________ Relationship __________________________________ Phone _____________________________________ High School Information High School Name _________________________________________________________ HS Code  High School Address _____________________________________________________________________________________ Street Phone _______________________________________ City State Zip Graduation Date ____________________________ Selective Service (to be completed by all males): Selective Service Number: _________________________________ To register on-line or for on-line verification of registration: www.sss.gov Registration Information Office: 1-888-655-1825 NOTICE: Under section 3345.32 of the Revised Code of the State of Ohio, if you are a male age 18 through 25, you are required to complete this information. Failure to do so will prohibit you from registering for classes. If you have not registered, you must indicate below the reason you are not required to register. I certify that I am not required to be registered with Selective Service, and I qualify for exemption for the following reason:  I have not reached my 18th birthday. College Credit Plus Program I understand that in accordance with provisions of law regarding College Credit Plus that if the course(s) are not completed successfully, I will be responsible for payment of tuition and fees to my high school. Further, I also understand that written permission must be obtained from the high school counselor or other authorized official before withdrawing from any course(s). If I am a student in a non-public school, I understand that, should the state choose not to fund my participation, I will be responsible for payment of tuition, fees, books and materials required for each course. Directory Information: Tri-C has designated the following information as directory information and will disclose this information without prior written consent unless otherwise instructed by the student: student name, address (local and home), program of study (including college of enrollment, major and campus), enrollment status (full time, part time, withdrawn), dates of attendance, degrees, honors, and awards received. The following will be disclosed for members of athletic teams only: previous educational institutions attended, participation in officially recognized activities and sports, weight, and height. Students who wish to have this information kept confidential should contact the Enrollment Center. By signing and dating this application, I certify that the information I have provided is complete and correct in every respect. • I understand that falsifying any part of this application may result in cancellation of admission. • I agree to abide by the policies, rules and regulations of Cuyahoga Community College. • I will bear full responsibility for any consequences resulting from my failure to promptly report a new address or change in name. I. Acknowledgement This application and all supporting documents become the property of Cuyahoga Community College and will not be returned to you or forwarded to another institution. I understand that Cuyahoga Community College will report grades and appropriate information to my high school counselor. ____________________________________________________________________________________________________________________ Signature of Parent or Guardian (Required) Relationship to Student Date ____________________________________________________________________________________________________________________ Signature of Student (Required)Date II. High School Acknowledgement I acknowledge that the above student is applying to the College Credit Plus Program. Comments: __________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Signature of Counselor or Authorizing Official (Required)Date ________________________________________________________________________________________________________________ Print Name and Title EmailTelephone # III. Final Steps You may apply for admission to take classes at any of Cuyahoga Community College’s locations but students should submit their completed College Credit Plus application to one of the four main campuses that is most convenient.  Eastern Campus  Metropolitan Campus  Brunswick University Center Enrollment Center 4250 Richmond Rd. Highland Hills, OH 44122-6195 216-987-2243 Enrollment Center 2900 Community College Ave. Cleveland, OH 44115-3196 216-987-4164 OR  Western Campus Enrollment Center 11000 Pleasant Valley Rd. Parma, OH 44130-5199 216-987-5155 / 216-987-5259  Westshore Campus OR  Corporate College West Enrollment Center 25425 Center Ridge Rd. Westlake OH, 44145-4122 216-987-5884 Step 1: Please submit your high school transcript with this application to your College Credit Plus coordinator. Step 2: You must complete the required assessment test in English in a Testing Center at the campus of application. Math assessment testing may be required depending upon course selection. The English assessment test must be completed before an admissions notification can be made. Appropriate ACT or SAT scores can be used in place of the assessment tests. IV. Acceptance The student is responsible for submitting all required information in a timely manner. You will be notified of your next steps in writing. 14-4716