Have you ever attended John Wood Community College (including dual credit courses)? Yes No
Please identify your primary racial/ethnic group. (select only one)
Asian American Indian or Alaskan Native Black or African American Hispanic or Latino
White Native Hawaiian or Pacic Islander Choose not to respond/unknown
Are you Hispanic or Latino? (Or are you of Spanish origin?)
Yes, I am Hispanic or Latino No, I am not Hispanic or Latino
Are you from one or more of the following racial groups? (Select all that apply)
Asian American Indian or Alaskan Native Black or African American
White Native Hawaiian or Pacic Islander Choose not to respond/unknown
Are you in the United States on a Visa?
No, I am a citizen of the United States
No, I am not a citizen of the United States, but am a legal resident alien or refugee.
Resident #________________
Yes, I am in the United States on a Visa Home Country of Origin:______________ Visa Type:__________
FERPA, the Family Educational Rights and Privacy Act of 1974, protects the privacy of student educational
records—To authorize, the student understands the information presented on this form and gives permission to the high
school and John Wood Community College to share, collaboratively, information related to his/her dual enrollment pro-
gram participation, as well as with his/her parent/guardian while enrolled in the concurrent enrollment course(s).
Granted access to parent/guardian listed below:
________________________________________________ ___________________________________________
Student’s Signature Date
________________________________________________ ___________________________________________
Parent/Guardian Signature Date Parent/Guardian Signature (optional) Date
________________________________________________ ___________________________________________
Parent/Guardian Name (print) Date Parent/Guardian Name (print) (optional) Date
________________________________________________ ___________________________________________
Parent/Guardian Email Address Parent/Guardian Phone #
FOR HIGH SCHOOL COUNSELOR ONLY
High school Transcript attached Geometry_______ Alg II________ UNW GPA________
(If needed)
SAT Critical Reading ________ Math_________
ACT Critical Reading ________ Math_________
ACCUPLACER ___________________________
Counselor Comments
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
____________________________________________ _______________________________________
Counselor’s Signature Date
Page 2 of 2
FOR JWCC OFFICE USE ONLY Reviewed:________ Date:________ SCH: (if applicable) _____ _____
FA SP
