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If you are interested in applying for a (Nassau Community College)

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If you are interested in applying for a Workforce Development Training Scholarship or for the Community Health Worker
Program, please review course information at: https://www.ncc.edu/continuingeducation/workforcedevelopment/
Then complete this application and the included FERPA Release Form and submit them along with any questions you
may have to: cwd@ncc.edu. You will be contacted once your application is reviewed. Thank you.
Last Name:
First Name:
Address:
City:
Zip:
Home Phone: ( )
Cell Phone: ( )
Birthdate: (mm/dd/yyyy)*
Gender Identity:
Have you taken courses at NCC? YES NO
If yes please provide your NCC ID #:
Preferred Email:
Alternate Email:
Demographics (Check all that apply): Ethnicity: Hispanic Non-Hispanic
Race: American Indian/Alaska Native Asian Black/African American
Native Hawaii/Other Pacific Islander White Other Multi-Racial
Income Level**:
# in Household: ____ Household Income: ________
Income Proof (choose one & attach):
High School Diploma or Equivalent YES NO
FERPA Release Form (see page 2) YES NO
*Applicants must be 17 years of age or older. **Attach any relevant documents.
This is an application form only. The Center for Workforce Development will contact the applicant to
complete the registration process, if the applicant is eligible and based on available funding.
CWD Course #^
Section
Course Title
Start Date
^For those interested in the Community Health Worker Program, simply note Course Title as “CHW Program.”
I certify that the above information is accurate to the best of my knowledge. While I have been assured that the information
is kept confidential, I am aware that it is subject to verification by the agency providing services, the Nassau County Office
of Community Development and/or HUD. I, therefore, authorize such verification, and will provide supporting documents if
requested.
Applicant Signature: _______________________________________ Date: _____________
Nassau County Workforce Development Programs
APPLICATION FORM
For Staff Use Only: Income Level: N-L Mod Low E-L Status: A. B. C. D. E. F.
NASSAU COMMUNITY COLLEGE
Federal Educational Rights and Privacy Act (FERPA) Record Release Form
I hereby give Nassau Community College (“NCC”) this written consent to release my grades,
transcripts, GPA information, and information regarding my academic progress,
____ Attendance_____________________________________________________________
Fill in additional information, if any, that you consent to being disclosed
to _Nassau County Office of Community Development, the financial sponsoring entity,
Name. Relationship to Student
Upon the above-named person(s)’ request, to keep the above-named person(s) apprised of my
educational progress at NCC. This written consent shall be valid for: the entire period I will be
enrolled at Nassau Community College.
I understand that this consent shall remain in effect for the time period stated above, unless revoked
by me, in writing, the written revocation to be delivered to NCC, but that any such revocation shall not
affect disclosures previously made by NCC prior to receipt of my revocation.
The parties acknowledge and agree that this document may be executed by electronic signature,
which shall be considered as an original signature for all purposes and shall have the same force and
effect as an original signature. Without limitation, “electronic signature” shall include electronically
scanned and transmitted versions (e.g., via pdf) of an original signature. “Electronic signature” shall
also include the typing of the signatory’s name on the signature line.
______________________________ ________________________________
PRINT NAME OF STUDENT DATE
______________________________ _______________________________
SIGNATURE OF STUDENT NCC Identification Number
To be filled in by Nassau Community College.
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Completed 3 February 2021

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