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Student First Name*Student First Name

Student Last Name*Student Last Name

Student Middle Initial*Student Middle Initial

SSN*SSN

Home Address*Home Address

Home City*Home City

Home State*Home State

Home Zip Code*Home Zip Code

County of Residence* Please Select Essex Franklin Hamilton St. Lawrence Lewis Clinton Warren WashingtonCounty of Residence

Date of Birth*Date of Birth

High School Level

Junior

Senior

High School Level

Home High School*Home High School

College Bridge Program Location*College Bridge Program Location

Family Telephone Number*Family Telephone Number

Student Email Address*Student Email Address

Gender

Female

Male

Other/Non-Binary

Gender

Citizenship

I am a US Citizen

I am not a US Citizen

I am an international student

Citizenship

Ethnicity (optional) Please Select American Indian/Alaskan Native Native Hawaiian/Pacific Islander Asian White Black/African American Hispanic Two or More RacesEthnicity (optional)

Signature

I understand I am formally enrolling in courses offered by NCCC at my high school. I understand that NYS Education Law allows me to enroll in these courses without a signature from my parent or guardian. I am responsible for paying $60 for each course I select below unless I formally drop these courses before October 25, 2020.

Signature

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