Application form

If you see this don't fill out this input box.

Please select a term Please Select Fall Winter/Spring Summer

Please select a year Please Select 2020-2021 2021-2022 2022-2023 2023-2024 2024-2025 2025-2026

Last name*

First name*

Middle name*

Preferred name

Address*

City*

State*

Zip code*

High School*

Year of Graduation from high school

Social Security Number (if you have one)

Gender

Male

Female

Other

Date of birth*Month/ Day/ Year (xx/xx/xxxx)

Home phone*

Cell phone

Email address*

Have you completed an NSCC or other college course(s)?

Yes

No

Has either parent graduated form a 4-year college?

Yes

No

Ethinicity information (optional)

Are you Hispanic/Latino?

Yes

No

Please check any that apply

American Indian or Alaska Native

Asian

Black or African-American

Cape Verdean

White

Native Hawaiian or Pacific Islander

COURSE CHOICES

Course Choice #1 CRN

Course Choice #1 Course Code

Course Choice #1 Course Title

Course Choice #1 Number of Credits

Course Choice #2 CRN

Course Choice #2 Course Code

Course Choice #2 Course Title

Course Choice #2 Number of Credits

STUDENT SIGNATURE VERIFICATION (check ALL boxes)

If accepted to the Early College Dual Enrollment Program at North Shore Community College, I agree to adhere to the North Shore Community College code of Student Conduct as outlined in the NSCC Student Handbook found at northshore.smartcatalogiq.com/en/current/Credit-Catalog/Student-Handbook

AGREE

I hereby authorize the release of my academic and student records by North Shore Community College for legitimate educational purposes.

AGREE

I understand that if I do not authorize the release of my academic and student records, it is my responsibility to obtain copies of my NSCC / Dual Enrollment academic transcript for my high school records.

AGREE

I understand that if I withdraw from a course after the official add/drop period, there will be consequences to my academic record.

AGREE

I certify that all information stated on this application is accurate and complete.

AGREE

STUDENT Signature and DATE*By typing NAME you are verifying this as a signature

PARENT Signature and DATE*

PARENT phone number

PARENT email address

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