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Dual Enrollment Application – Returning Student
Semester: Fall 20___ Spring 20___ Summer 20___
Section 1 – Student Information and Signatures
Name: CCCC Student ID #:
Last Name First Name
Mailing Address: Student Cell Phone: ( )
Street
Student Email:
City/Town State Zip Code
High School Year of HS Graduation:
Student: If accepted into the Dual Enrollment program, I agree to adhere to all rules, regulations, and requirements.
STATEMENTS OF UNDERSTANDING
Student: If accepted into the Dual Enrollment program, I agree to adhere to all rules, regulations, and requirements
set by Cape Cod Community College and/or the Massachusetts Department of Higher Education. I understand that CCCC reserves the
right to disclose my status as a high school student to CCCC faculty members. I hereby authorize Cape Cod Community College
to release all correspondence regarding my enrollment in the Dual Enrollment program to my high school and to forward an
official report of my grades to my high school. I understand that course-related costs including tuition, fees, and textbooks are
not covered under the Dual Enrollment Program. I verify that I have read the Dual Enrollmen
t Application and Eligibility
Requirements packet, and I understand that I must meet with an Admissions counselor to register for my classes.
Signature of Student: Date:
Parent/Guardian: I hereby grant permission for my child to apply to the Dual Enrollment Program at Cape Cod Community
College. Should my child be accepted, I grant permission for him/her to enroll in courses at the College. I understand that
course-related costs including tuition, fees, and textbooks are not covered under the Dual Enrollment Program. I understand
that my student’s CCCC academic records will be released to his/her high school for inclusion in his/her school records.
Parent/Guardian Na me (please print):
Signature: Date:
Emergency Contact: Emergency Teleph
APPLICATION FOR GRANT AWARD – This section is required for students interested in applying for financial assistance.
Students will not be considered for funding if left blank. Applying does not guarantee an award.
CCCC may have some limited funds from the Commonwealth Dual Enrollment Partnership and from the Cape Cod Community College Whitehouse fund that can
be used to help eligible students with the of one course. Eligible students will have financial need, be a first generation college student (neither parent has a
bachelor’s degree), and/or be a member of an underrepresented group at CCCC.
Student’s Social Security Number: - -
Parent/guardian educational background:
Parent/guardian #1 has a bachelor’s (or higher) degree:
Yes No
Parent/guardian #2 has a bachelor’s (or higher) degree:
Yes No
Household Size and Income:
Family Size: ________ Please include yourself, parents/guardians and siblings that live with you.
Total Household Income (Gross): $ $ $
Year OR Monthly OR Weekly
