12/2015
Plus 50 Encore Completion Program Intake Sheet
Student: ______________________________________ ________________________________
LAST NAME FIRST NAME
Address: ________________________________________________________________________
County: ______________________________
City: ________________________________ State: __________________ Zip: ____________
Phone: ______________________________ Email: ____________________________________
Gender:
☐ Male ☐ Female Date of Birth: ______________________________
Ethnicity: optional (Check One)
☐ American Indian or Alaskan Native ☐ Hispanic or Latino ☐ Asian
☐ Native Hawaiian or Pacific Islander ☐ Black/African American ☐ White
Program Intent: (Check One)
☐ Case Management ☐ Addiction Studies ☐ Mental Health
Other: __________________________________________________________________________
Additional Student Information:
Do you receive Financial Aid?
☐ Yes ☐ No
Are you a current WCCCD student?
☐ Yes ☐ No
Are you a current Plus 50 student participant?
☐ Yes ☐ No
Options to submit form: • Click ‘Submit’ or email to ckaramo1@wcccd.edu
• Fax to 313-964-1487
• Bring to Wayne County Community College District
School of Continuing Education and Workforce Development
801 W. Fort Street, Detroit, MI 48226
