Central Community College is an affirmative action/equal opportunity institution 02/14/19
Parent/Guardian:
Signature_________________________________________________________Date___________
Printed Name____________________________________________________________________
Phone Number ____________________________________________
E-mail address___________________________________________________________________
CCC Student ID #_____________________
Early College Registration
Step 1: If you have not completed your online profile, go to www.cccneb.edu/createaccount
Step 2: Attach ACT or NWEA MAP Student Progress Report if scores are needed for pre-requisite
Step 3: Complete form below, including Parent/Guardian signature
Please print using black ink
Home Phone Number Cell Phone Number
Home/Mailing Address (PO Box/Street)
Year of high school graduation:
Early College Staff only: Career Pathway
Date of Birth: Month_____Day____Year_____
Gender: Male Female
Ethnicity:
Race:
First-time Early College Students
The Central Community College Early College program provides opportunity for currently enrolled high school students to enroll in
college credit classes. In order to do this, the student must meet the pre-requisite requirement by equivalent college-level worked
provided on a transcript or demonstration of meeting pre-requisite through assessment measures.
Students must abide by all college rules and regulations. A copy of the CCC Student Policies and Procedures may be found at
www.cccneb.edu/StudentPoliciesandProcedures.
Course Enrollment
Location:__________________________
Term:_____________________________
Total Credits______
We (student and parent/guardian) have read and understand the conditions of this form. We
understand that by signing this form, we are responsible for all tuition and related fees unless
the student officially drops the course(s) or withdraws from Central Community College by the
established deadlines.
As the student, I allow Central Community College to release information relative to my
academic progress to my high school and to my parents/guardians. I also allow release of my
standardized test scores to Central Community College.
Student Signature_______________________________________________________Date___________
ACE Scholarship
Check#______________
Cash
Credit Card-Please call
402-562-1226 to make a
credit card payment
Bill Me
School District
________number of credits
School District Signature required:
Hispanic or Latino
Am Indian/Alaskan Native
Not Hispanic or Latino
Native Hawaiian/or Other Pacific Islander
Asian Black or African American
White
