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Application form
Early College Dual Enrollment
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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
Form UUID
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