Senior Citizen Enrollment Request
LFCC Admissions / Enrollment Services Office
173 Skirmisher Ln · Middletown, VA 22645
Telephone: 540-868-7110 Email: admissions@lfcc.edu Fax: 540-868-7005
Revised 10/17/2019 YELLOW
For office use only
Electronic signature verified by: _________________ Processed by: _____________ Date __________________
Semester: □ Fall □ Spring □ Summer Year: 20____
Student ID# Date of Birth
Name
Last First Middle
Phone Email
Enroll or Add
Class # Subject Course # Section Credits X if Audit
Example: 43564 ART 153 100M 3 X
NOTE: You will be enrolled on the first day of classes on a space available basis.
Check option that applies:
Option 1: I certify that I qualify for free tuition for Credit Courses, part-time or fulltime, under the Senior Citizens
Higher Education Program and I meet the following criteria:
1. Be 60 years of age or older.
2. Be a legal resident of Virginia for one year or more prior to the start of the term. Supporting
documentation may be required.
3. Have an income not exceeding $23, 850 for Virginia tax purposes for the year preceding the
semester in which enrollment is sought. (You must provide a copy of the previous year’s Virginia
tax return if you are seeking academic credit.)
Option 2: I certify that I qualify for free tuition for Audit of Credit Courses, part-time or full-time, under the Senior
Citizens Higher Education Program and I meet the following criteria:
1. Be 60 years of age or older.
2.
Be a legal resident of Virginia for one year or more prior to the start of the term. Supporting
documentation may be required.
Student’s Signature Date
I voluntarily consent to the use of an electronic record of my LFCC student file. I acknowledge that, by logging into the MYLFCC system with my unique credentials and e-
mailing from my @email.vccs.edu account to provide LFCC with this data, I have given my electronic signature which has the same legal and binding effect as a "wet" or
handwritten signature.
