902 Herring Ave. • Wilson, NC 27893 • 252-291-1195
Student Information
Applying for Career and College Promise (CCP): College Transfer or Career Technical Education (curriculum or
workforce continuing education pathways)
College ID (Leave Blank)
First Name Middle Name Last Name (Jr., Sr., III) Date of Birth (MM/DD/YYYY)
Street Address City, State Zip
Home Phone Cell Phone Gender
Email Address Social Security Number*
Ethnicity: Please select one.
q Hispanic/Latino q Non-Hispanic/Latino
Hispanic/Latino: Mexican, Puerto Rican, Cuban, Central
or South American or other Spanish origin or culture, regardless of race.
Race: Please select all that apply.
q American Indian/Alaska Native q Asian
q Black/African American q White
q Native Hawaiian/Other Pacific Islander
q Other
College Educational Goals q Transfer Credit to College q Degree, Diploma, or Certificate q Develop Job Skills q Goal Unknown
*Your social security number is not required, but requested solely to identify student records within our information processing system. It serves to ensure that the College will maintain data such as
name, address, grades, etc., in an accurate manner. Your social security number is not shared or released.
Emergency Contact Information
Name Address Phone Number Relationship
High School and Academic Information (Currently Enrolled HS Students Only)
High School Name Current Grade
Anticipated Graduation Date (MM/YYYY)
Student Agreements
Application Agreement and Release of Academic and Enrollment Information
I certify that all information herein is true and complete to the best of my knowledge. I understand if found to be otherwise, it may cause a delay of admission, loss of credit, and/
or dismissal. I therefore consent to the release of transcripts to Wilson Community College. I acknowledge that the institution may verify the information herein from sources
accessible under law to the institution; however, the institution may disclose the contents of this application only as permitted under the Family Educational Rights and Privacy
Act of 1994.
Information pertaining to your academic record is protected by the Family Educational Rights and Privacy Act of 1974 (FERPA). College personnel are not allowed to disclose
information regarding your grades, attendance, or any other academic matter with another person, or in the presence of another person, without your prior written approval. The
College may release information to school oicials with legitimate educational interest and that information can only be released in accordance with FERPA regulations. By signing
this form, I give permission to WCC to discuss any of my academic information with my parent(s)/guardian(s) and authorized personnel at my high school.
Student Agreement
I understand that college level work requires a high level of maturity, independent learning, and a willingness to take responsibility for completing assignments on time with high
quality and academic honesty. I also agree that it is my responsibility to contact the instructor immediately if a circumstance arises that could aect my attendance or completing
work on time. I have read the above information, and I agree to abide by WCC’s policies & procedures.
Student Signature Date
Parent or Guardian Signature (Strongly Recommended)
By signing this form, I understand the student above is enrolling in Wilson Community College through the CCP program. Courses taken will be listed on the high
school and college transcripts. College students must abide by all Wilson Community College policies & procedures.
Parent or Guardian Date
The College expressly prohibits any form of unlawful discrimination or harassment based on sex; race; color; national origin; age; religion; disability; citizenship; status as a Vietnam era, special disabled,
or other covered veteran; or status in any group protected by law.
Revised 07/09/2020
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