HIGH SCHOOL DIPLOMA COMPLETION INITIATIVE
APPLICATION FORM
Please complete and return this application when you attend the informational meeting. For questions call 517-483-9707.
Date of Birth Last Name First Name Middle Name
Street Address City state zip
Student (Cell) phone number parent/guardian phone number
Student email parent/guardian email
last high school attended
Are you currently ‘Dropped out’ of school? YES NO Last date attended high school / /
Education Goal High School Diploma Certicate of Achievement Certicate of Completion
(Choose all that apply) Associate Degree Transfer to Four-Year School
How many hours per week do you Not Working 1-20 Hours/Week
Plan To Work While In Hsdci? 21-40 Hours/Week More Than 40 Hours/Week
Parent’s Highest Parent 1 High School Two-Year College Four-Year College Graduate Degree
Educational Level* Parent 2 High School Two-Year College Four-Year College Graduate Degree
Ethnic American Indian or Alaska Native Hispanic or Latino (All Other Races) Other
Background* Asian Hispanic or Latino (White) White
Black or African American Native Hawaiian or Pacic Islander
Citizenship U.S. Citizen Permanent/ Refugee, Immigrant, Gender* Female Male
Resident Political Asylum
* The information requested in this box is VOLUNTARY and will be held in condence. This information is needed for summary reports and will not be used as a factor in the admissions process.
Lansing Community College complies with all federal and state requirements, which include collecting this information. Failure to respond will not result in any negative action against you.
The above information is correct and complete to the best of my knowledge.
Parent/Guardian signature is required if student is under 18:
Student Signature DATE
Parent/guardian name
Parent/guardian Signature DATE
LANSING COMMUNITY COLLEGE
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APPLIACTION FORM
Lansing Community College is accredited by the Higher Learning Commission (hlcommission.org), a regional accreditation agency recognized by the U.S. Department of Education. Lansing Community College does
not discriminate against individuals in its programs or activities on the basis of race, color, sex, age, religion or creed, national origin or ancestry, familial status, disability, pregnancy, marital status, height, weight,
sexual orientation, gender, gender identity, genetic information, veteran or military status, or any other factor prohibited by law. The college’s discrimination and harassment policies are available at lcc.edu/policy.
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