Student Name _______________________________________
Student Application
Registration Date:
Class location:
Dublin
Which credential do you want to attain in Middle College:
NRV Mall
GED
High School Diploma
I agree to the release of my information for the purposes of my participation in the Middle College program. I understand
that in order to be accepted in the Middle College Program that I must fulfill all program components: (1) GED/HS
Diploma, (2) Career Planning, (3) WorkKeys, and (4) College Transition.
Signature _______________________________________________________________________________________ Date
STUDENT INFORMATION:
Name:
Parent Name
Mailing Address:
City
State
Zip
E-mail Address:
Home Phone #:
Alternate Phone #:
Emergency Phone #:
Do you have a social networking site? If so, check which ones:
Facebook
Birth Date:
Ethnicity:
Age:
Social Security #:
Gender:
M
F
MySpace
Twitter
Other
How long have you lived in Virginia?
How did you find out about Middle College?
Check all that apply:
Disability
Are you a U.S. Citizen?
Are you currently employed?
Public Assistance
Yes
Medical Conditions
No
Yes
No
How many hours per week do you work?
What is your career goal?
Food Stamps
Undecided
If yes, where are you employed?
What is your work schedule?
Day
Night
Both
Military
I will need to arrange a Financial Plan for Tuition Assistance for my high school credits:
Yes
I understand that if I’m under the age of 18 that I will not qualify for financial aid for college credits:
No
Yes
No
Student Name _______________________________________
PREVIOUS SCHOOL INFORMATION:
Homeschooled:
Yes
No (If no, continue answering the questions in this section.)
Last School Attended:
Location (city/state):
Last Year Attended: 19
Last Grade Level Completed:
9th
/ 20
10th
Year entered the 9th grade:
11th
12th
FOR GED SEEKING STUDENTS: Have you ever been enrolled in a GED Program?
Have you ever taken the GED?
Yes
No
Yes
No
If yes, where?
If yes, what were your GED scores for the following tests?
Writing
Reading
Social Studies
Science
Math
FOR DIPLOMA SEEKING STUDENTS: Reason for enrolling in NRCC’s diploma program:
Approximately how many credits have you earned?
How many verified credits do you have?
Application for Virginia In-State Tuition Rates:
Eligibility for in-state tuition is pursuant to Section 23-7.4 Code of Virginia.
FAILURE TO COMPLETE AND RETURN THIS FORM WILL RESULT IN AN OUT-OF-STATE CLASSIFICATION FOR TUITION
PURPOSES. All students taking credit classes must complete this portion of the application. Please contact the NRCC Admissions
and Records Office with your questions.
1. Applicant’s Name:
First
Middle
Last
Date of birth:
mm
/
dd
/
yy
2. Please choose the domicile on which you want to base your eligibility for in-state tuition:
Parent’s Domicile: Choose this option if you receive over half of your financial support or you are claimed as a tax dependent
by your parents.
Legal Guardian’s Domicile: Choose this option if you are under the custody of a court-appointed legal guardian.
Spouse’s Domicile: Choose this option if you are married and want to claim eligibility for in-state tuition based on your
spouse’s domicile.
Your Domicile: Choose this option if you want to claim eligibility for in-state tuition based on your own domicile.
If you are under the age of 24, your eligibility must be based on your parent or legal guardian unless one of the following applies:
(Check all that apply.) You may be required to supply “clear and convincing evidence” of your status.
I am a veteran or active duty member of the U.S. Armed Forces.
I have legal dependents other than my spouse.
I am a ward of the court or was a ward of the court until age 18.
I am enrolled in graduate school.
Both of my parents are deceased and I have no adoptive or legal guardian.
I am married.
I can present clear and convincing evidence that I am financially self-sufficient.
3. Provide the name of the person upon whom you are basing your domicile:
First
Middle
Last
4. Answer the following questions for the entire 12 months prior to the term in which you enroll, will the person in Question 3 have:
• continuously lived in and continue to live in Virginia?
Yes
No
Student Name _______________________________________
• filed a tax return or paid income taxes to Virginia?
• been a United States citizen?
Yes
A# _______________________________________
Yes
No Income
Income in another state
No If no, been a permanent alien resident?
• been registered to vote in Virginia?
Yes
Not Registered
• held a valid Virginia driver’s license or Virginia DMV ID?
Yes
• owned or operated a motor vehicle registered in Virginia?
Yes
No If yes, provide the
Registered in another state
No license or ID
Yes
Licensed in another state
No vehicle
Registered in another state
• lived outside of Virginia, but worked in Virginia, earned at least the equivalent of full-time wage salary, and paid Virginia income
taxes on all taxable income in this Commonwealth?
Yes
No
• filed a tax return or paid income taxes to a state other than Virginia?
Yes
No If yes, paid or filed in what state?
MILITARY INFORMATION
5. Is the person listed in Question 3 on active duty with the military?
Yes
No If yes, provide the state listed on the Leave
and Earnings Statement (LES) and the date when it became effective for this state: State:
Effective Date:
/
/
mm
Is the person listed above stationed in Virginia pursuant to orders?
the orders to Virginia. :
/
/
mm
dd
Yes
dd
yy
No If yes, provide the reporting date listed on
yy
If yes, will the spouse of the person in Question 3 have resided in Virginia, earned at least the equivalent of a full-time wage salary and
paid income taxes to Virginia for one year prior to the start of the term in which you will enroll?
6. Has the person listed in Question 3 retired or been discharged from the military?
retirement or discharge date:
/
/
mm
dd
Yes
Yes
No
No If yes, provide the
yy
7. Is the spouse of the person listed in Question 3 on active duty with the military?
Yes
on the Leave & Earnings Statement and the date when it became effective for this state: State:
No If yes, provide the state listed
Effective Date:
/
/
mm
Is the spouse of the person listed in Question 3 stationed in Virginia pursuant to orders?
reporting date listed on the orders to Virginia. :
/
/
mm
dd
Yes
dd
yy
No If yes, provide the
yy
If yes, will the person in Question 3 have resided in Virginia, earned at least the equivalent of a full-time wage salary and paid income
taxes to Virginia for one year prior to the start of the term in which you will enroll?
Yes
8. Has the spouse of the person in Question 3 retired or been discharged from the military?
retirement or discharge date. :
/
/
No
Yes
No If yes, provide the
mm
dd
yy
Please note: If you knowingly provide erroneous information to evade payment of out-of-state tuition and fees, you will be charged out-ofstate tuition and fees for each term attended and may be subject to dismissal. Random audits of this information will be performed. I certify
under penalty of disciplinary action that all of the information is complete and accurate. I agree to supply the college with supporting
documentation related to my application, if I am requested to do so.
Signature of Applicant
Date
Signature of Parent, Legal Guardian or Spouse
Date
Please print this completed application and mail to:
New River Community College
Middle College
ATTN: Jenny Bolte
P.O. Box 1127, Dublin, Virginia 24084
*Do not E-Mail or Fax this document
Student Name _______________________________________
FOR STAFF USE ONLY
STUDENT PROGRAM OF STUDY INFORMATION:
Program Start Date:
Date TABE Completed:
Pre-TABE: Applied Math
Reading
Workkeys Test Date:
Post-TABE: Applied Math
Scores: Reading
Math
Reading
Locating Information
Date Virginia Wizard Completed:
Date FAFSA Completed:
Career Readiness Certificate Earned:
Bronze
NRCC Start Date
Silver
Gold
GED SEEKING STUDENTS:
Official GED Practice Test Scores: W
R
SS
Check which areas the student needs preparation:
W
Sc
M
R
SS
Sc
M
Date GED Completed:
FOR DIPLOMA SEEKING STUDENTS:
CompuHigh (MCHS)
APEX (VHS: Diploma Issued by
For VHS Students Only: Diploma Type
Standard
Adult
Number of Subjects to Complete for Diploma:
Student Requests Financial Plan:
Yes
Date Approved
)
GAD
Tuition Amount Due:
No
Check Subjects Needed to Complete:
ENGLISH (4 Required)
English 9
English 10
English 11
English 12
MATH (MCHS: 2 Required; VHS: 3 Required)
Algebra l
Algebra II
Geometry
Pre- Algebra
Practical Math
SOCIAL STUDIES (2 Required)
American Government
American History
Modern World History
World Geography
SCIENCE (w/ labs) (2 Required)
Environmental Science
Biology
ELECTIVES (MCHS: 8 NRCC Classes Required; VHS: 5–9 NRCC or Apex Classes Required) List Electives Here:
Student Name _______________________________________
DIPLOMA PROGRAM PLAN INFORMATION:
Semester One:
Start Date:
Summer
Fall
Anticipated Completion Date:
Class
Spring
Year: 20
Day(s) of Week
Time
1
2
3
4
Semester Two:
Start Date:
Summer
Fall
Anticipated Completion Date:
Class
Spring
Year: 20
Day(s) of Week
Time
1
2
3
4
Semester Three:
Start Date:
Summer
Fall
Anticipated Completion Date:
Class
Spring
Year: 20
Day(s) of Week
Time
1
2
3
4
Semester Four:
Start Date:
Summer
Fall
Anticipated Completion Date:
Class
Spring
Year: 20
Day(s) of Week
Time
1
2
3
4
Semester Five:
Start Date:
Class
Summer
Fall
Anticipated Completion Date:
Spring
Year: 20
Day(s) of Week
Time
1
2
3
4
Date Application Sent to AE Data Specialist and AHS Coordinator