Smart Start
application &
courSe regiStration
Students are responsible for tuition and fees associated with classes (Estimated cost: traditional - $163 per credit
hour; online $193 per credit hour. Rates set by the board by June 2019 for fall 2019 semester).
Books for classes can be purchased through the JWCC Bookstore. Please call 217.641.4230.
Availability is limited—Payment due one week prior to start of class. Please call 217.641.4207 to pay by credit or
debit (payment plans available). Submit form to JWCC Enrollment Services (smartstart@jwcc.edu).
High School Name____________________________________
Anticipated graduation date________________________________
(Please PRINT and ll out COMPLETELY - Return form to JWCC Enrollment Services)
Name: _________________________________________________________________________________
Last First Middle Initial
Address: _______________________________________________________________________________
Preferred Email: __________________________________________________________________________
Phone: _________________________________________ Gender: Male Female
SSN: |__|__|__| - |__|__| - |__|__|__|__| Date of Birth: _________________________
(Social Security Number)
Please check online at jwcc.edu to see a full listing of course offerings.
OFFICE OF ADMISSIONS
1301 South 48th St | Quincy, IL 62305
217.641.4339 | Fax: 217.221.0778
smartstart@jwcc.edu
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Fall 2019 (August Start)
Check
Course
Selection
Course
Prex
Course
No.
Attending
Center
Course
Cr.
Hrs.
Spring 2020 (January Start)
Check
Course
Selection
Course
Prex
Course
No.
Attending
Center
Course
Cr.
Hrs.
Earn College Credit
in High School
John Wood Community College
Unity High School
SCI
100
UHS
Environmental Geology - J. Stapleton
4
BIO
101
UHS
4
ENG
101
UHS
Rhetoric & Composition I
3
ENG
102
UHS
3
HIS
101
Online
Western Civilization I
3
CMN
101
UHS
3
HIS
102
Online
Western Civilization II
3
HIS
101
Online
3
HIS
121
Online
US History I
3
HIS
102
Online
33
HIS
122
Online
US History II
3
HIS
121
Online
3
HUM
101
Online
Intro to Humanities - 8wks
3
HIS
122
Online
3
MAT
109
Online
Elementary Stats - ALEKS
3
HUM
101
Online
3
MAT
113
Online
College Algebra - ALEKS
3
MAT
109
Online
3
MAT
114
Online
Trigonometry - ALEKS
3
MAT
113
Online
3
OFT
281
Online
Medical Terminology
3
MAT
114
Online
3
PHL
201
Online
Major World Religions
3
OFT
281
Online
Medical Terminology
3
PSC
101
Online
American Government
3
PHL
201
Online
Major World Religions
3
PSY
101
Online
Intro to Psychology
3
PSC
101
Online
American Government
3
SOC
101
Online
Intro to Sociology
3
PSY
Intro to Psychology
101
Online
3
SPN
101
Online
Elementary Spanish I
4
SPN
Elementary Spanish II
102
Online
4
NUA
101
North Adams
Basic Nurse Assisting
6
NUA
103
North Adams
Nursing Assistant Practicum
1
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 Pacic 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 Pacic 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
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FOR JWCC OFFICE USE ONLY Reviewed:________ Date:________ SCH: (if applicable) _____ _____
FA SP
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