One College Drive
Calais, ME 04619
Enrollment & Student Services 207-454-1034
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 454-1094.
RE – Form Add Change Program pc: Advisor
Revised: July 8, 2019; amd Financial Aid
Student
Add/Change Program
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
Student ID #: _____________________________ Email address: ______________________________________________________
Advisor: _____________________________ Current Program of Study: ________________________________________________
Change program of study from ______________________________________ to _______________________________________
Certificate Diploma Associate Degree
OR
Additional program of study (If you are adding to your existing program)*: ______________________________________________
Certificate Diploma Associate Degree
*NOTE*: The following Programs require a Student Disclosure of Criminal Convictions Form (SDCCF) to be completed before
adding: Criminal Justice, Early Childhood Education, Education, Human Services, Medical Assisting, and Phlebotomy. Please attach
completed SDCCF to this form. The following programs require additional immunizations for Hepatitis B, Varicella, and Purified
Protein Derivative (PPD): Medical Assisting and Phlebotomy. Please attach completed immunization documentation to this form.
Please submit completed form to Anne Donahue, Coordinator of Enrollment & Student Services.
Student Signature: _______________________________________________________________________Date:________________
Advisor Signature: _______________________________________________________________________Date:________________
Coordinator of Enrollment & Student Services: _________________________________________________Date:________________
For Office Use Only
Processed: __________________ __________________
Initials Date
