One College Drive
Calais, ME 04619
Admissions Office 207-454-1000
Instate: 800-210-6932
Fax: 207-454-1092
Non-Discrimination Policy
: Washington County Community College is an equal opportunity/affirmative action institution and employer.
For more information; please call Tatiana Osmond, Affirmative Action Officer, at 207-454-1094.
AD – Form Admission Deposit
Revised: July 31, 2019; amd
Admission Deposit Form
Please return this form to WCCC with your $75.00 admission deposit, within 30 days of receipt of your acceptance letter to secure
your space in the program. Make your check or money order payable to Washington County Community College. For credit card use,
contact Heather Smale, Student Account Representative 207-454-1025.
Last Name: ___________________________________ First Name: __________________________________ M.I.: _____________
Mailing Address: _______________________________________ City: ______________________ State: _________ Zip: ________
Phone Number: ___________________________________ Mobile Phone Number: ________________________________________
Cell phone carrier: US Cellular Verizon AT & T Tracfone Other __________ Text Updates: ___Yes ___No
Social Security #: ___________________________ Email address: _____________________________________________________
Program of Study:____________________________________________________________ Date of Birth:_____________________
EMERGENCY CONTACT
Closest Living Relative/Spouse: ________________________________________________________________________________
Relationship:_____________________________ Email address: ______________________________________________________
Mailing Address: ______________________________________ City: ______________________ State: _________ Zip: ________
Phone Number: ____________________________________ Mobile Phone Number: _____________________________________
Name of Health Insurance Company: ______________________________ Policy Number: ________________________________
Name of Policy Holder: _____________________________________________
LOCAL NEWSPAPER
This information is used to publish academic successes of WCCC Students.
Name of Newspaper:_________________________________________________________________________________________
Mailing Address: ______________________________________ City: ______________________ State: _________ Zip: ________
Email address: ______________________________________________________
Placement in the program of study is not secured until the admission deposit is received. This deposit is credited toward your
upcoming semester charges and is not an additional fee. Should you decide not to attend WCCC, this deposit can be refunded up to
120 days prior to semester start date.
Student Signature: _______________________________________________________________________Date:________________
For Business Office Use Only
Date Received: _____________ Receipt #:____________ Received By:_____________
For Admission Office Use Only
Processed: __________________ __________________
Initials Date
