North Central Connecticut College Career Pathways Consortium Asnuntuck Community College

Student Information/College Career Pathways Application

High School:______Year of graduation or completion of H.S. diploma

Name:______Last First MI

Address:______Street City State 06082

Telephone: ( )______Date of Birth_____/______/_____ SSN:______/______/______

Applicants are requested to complete this information:

1. Gender: Male______Female_____

2. Do you speak another language at home other than English? Yes______No______

3. Parent or Guardian’s Name(s)______

4. Please check the program area(s) that best describe your Program of study and indicate below the College Career Pathways courses for which you are enrolling:

General Education______College Prep______Technical_____ Other______(specify)______

Academic Year High School Course(s) and credit Asnuntuck Course Equivalent

The undersigned agrees that the information on this application is true and accurate and will be kept according to the provisions of the Privacy Act. Misleading or false information may result in rejection or dismissal. The Undersigned also agrees to release all relevant academic records for the purposes of the program.

Applicant’s Signature______Date______

Parents/Guardian Signature______Date______

Guidance Counselor’s Signature______Date______

Site Coordinator’s Signature______Date______

Non-Discrimination Policy: Asnuntuck Community College does not discriminate on the basis of race, color, national origin, ancestry, religious creed, age, gender, marital status past or present history of mental disorder, mental retardation or physical disability, prior conviction of a crime, sexual orientation, or political affiliations in admitting students to its program or in administering its educational policies, admissions policies, loans and scholarship programs, athletics, and other institutionally administered programs or activities generally made available to students at the college. Please return to Guidance Counselor or College Career Pathways Coordinator North Central Connecticut College Career Pathways Consortium Asnuntuck Community College High School:______Year of graduation

Date:______

Name:______Last First MI

Advisor/Guidance Counselor:______

Grade 9 Grade 10

Math ______Math______

Science ______

Science______English______

English______Technology______

Technology______Other required courses______

Other required courses______

Grade 11 Grade 12

Math ______Math______

Science ______

Science______English______

English______Technology______

Technology______Other required courses______

Other required courses______

Program Criteria to Receive ACC Transcript: 1. Minimum of three (3) years of math (including Algebra 1 or its equivalent, Geometry or its equivalent) 2. A minimum of four (4) years of English 3. A minimum of two (2) years of science 4. A minimum of (1) year of Business/Technology Education course 5. High School attendance requirements as set by the individual high school must have been met 6. Earn a passing grade of 80 or better in individual course to receive ACC credit hours 7. Written parental approval 8. Administrative approval 9. Guidance approval 10. Successful completion of high school diploma or GED Please return to Guidance Counselor