Calhoun Community College
APPLICATION FOR ADMISSION
CALHOUN
COMMUNITY
COLLEGE
Admissions Office
P.O. Box 2216 • Decatur, AL 35609-2216
256/306-2500 or 1-800-626-3628
www.calhoun.edu
Your Community. Your College. Your Future.
According to State Board Policy 801.01: Admission; All new/readmission students must provide one Primary Form of Documentation or Two
Secondary Forms of Documentation (one of which must be a picture ID) for Admission to Alabama Community Colleges. All International
Students must provide an acceptable VISA.
Documentation must be submitted in person to the admissions office -OR- a notarized copy may be mailed to the admissions office.
Registration for classes will not be allowed until the Admissions Office has received appropriate documentation.
PLEASE PRINT
Have you previously applied for admission to Calhoun? Yes No
Full Legal Name (optional)
Mr.
Ms.
Mrs.
Last
First
Please provide any former names you may have used while attending
high school or college (Please include first, middle, and last name).
Gender
M F
If yes, did you attend classes at Calhoun? Yes No
Social Security Number ________ - ________ - _________
MAILING ADDRESS
City
Home Phone:
Birth Date
State
Work Phone:
Cell Phone:
PERMANENT ADDRESS ( Check here if same as mailing)
City
State
Person to contact in case of emergency
TERM OF ENROLLMENT
Fall
Year _______
Spring
Summer
ENTRY STATUS
Accelerated high school student
Dual Enrollment/High School
First time freshman (high school graduate)
First time freshman (earned a GED)
Returning Calhoun student
Transfer student
Transient student
Senior citizen (60 or older)
Military
Military dependent
Did your parent(s) attend college?
Yes No
State of Birth
Country of Birth
Zip
County
E-mail:
PRIMARY REASON FOR ENROLLMENT
Suffix
County
_____________________________________
Middle
Zip
List your intended academic program
USE BLUE/BLACK INK
Earn a degree and transfer to another
college/university (A.A. or A.S)
Complete credits/courses for transfer to
another college/university
Earn a degree (A.A.S.) - Technical/
Occupational
Earn a certificate
Learn skills to attain a job
Learn skills to advance in job
Improve skills in English, reading and/or math
Take courses for personal interest
Take courses as a transient student
Telephone
CITIZENSHIP
U.S. Citizen
Permanent Resident (non-citizen)
Foreign Visa ___________________
Indicate country of citizenship if other
than U.S. _________________________
For statistical purposes only
ETHNIC ORIGIN
Hispanic
Non-Hispanic
Unknown
RACE (Check all that may apply)
White
Black/African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific
Islander
Non-Resident Alien
HIGH SCHOOL INFORMATION
High School Last Attended
City, State
Date of High
School Graduation
If you earned a GED, please list when and where it was completed.
Year ________________
or anticipated
______________
Location _______________________________________State __________________
Select one of the following:
Standard Diploma
GED**
Advanced Diploma
Did Not
Credit Based Diploma
Graduate**
Occupational Diploma*
Certificate**
* Applicants must meet additional admission criteria.
** Only eligible for enrollment if a GED completed.
COLLEGE INFORMATION
List ALL colleges attended (most recent first)
City, State
INSTITUTION(S)
Dates of Attendance
From ________/________
To _________/________
From ________/________
To _________/________
From ________/________
To _________/________
From ________/________
To _________/________
Are you on suspension from last college/university attended?
Did you Graduate?
Yes
No
Yes
No
Yes
Yes
No
No
If yes, type of degree
____________________
Yes No
PLEASE READ CAREFULLY AND SIGN
I certify that I comply with the provisions of the United States Military Selective Service Act (50 U.S.C. App 453) by having registered with the
Selective Service Board or that I am not yet 18 years of age and I will register when required or that I am not required by law to register. (This
certification is required by State of Alabama Legislative Act 91-584.)
I, the undersigned applicant for admission, understand that withholding information requested in this application, or giving false information,
will make me ineligible for admission to, or continuation in, Calhoun Community College. I agree to abide by the rules, policies, and regulations
of the college as stated in the Student Handbook and College Catalog. With this in mind, I certify that all statements contained herein are correct and complete and I further agree that if any of the information I am providing herein shall be discovered by Calhoun Community College to
be false or incomplete, then the College shall have the right, at its sole discretion, to suspend or discontinue my enrollment for such period of
time as the College shall deem appropriate. In addition, I agree that should such suspension or discontinuation of enrollment begin during an
academic term, I shall not be entitled to any refund of tuition or fees nor shall I be entitled to receive any grade or credit for the subject term except to the extent deemed appropriate by the College.
If I am a dual enrollment student, I hereby authorize Calhoun Community College to release my academic record to my high school.
______________________
Date
Cond Letter
_______________________________________________________________________________
Comments:
Signature
FOR OFFICE USE ONLY
Calhoun Community College is committed to equal opportunity in employment and education. The College does not discriminate in any
program or activity on the basis of race, color, religion, gender, age, national origin, disability, marital status or any other protected class.
Rev. 6/10
Office of Admissions & Records
Signature Page
This form along with a legible copy of your primary state or federal
identification may be emailed to admissions@calhoun.edu.
All students applying for admission must complete this form. Residency guidelines are set by the Alabama Community College System.
Printed Full Name: ____________________________________
Date of Birth: _____/_____/______
Month
Please read the following statements and check the one that applies to you.
Day
Year
Student ID#: __________________
1.
______
I qualify as an in-state student based upon one of the following:
• I support myself financially, and I (or my spouse) have lived in the state of Alabama for at least 12 months.
• I am a dependent student, and my supporting person has lived in the state of Alabama for at least 12 months.
• I will graduate or have graduated from an Alabama high school or obtained a GED in the state of Alabama within
three years of my application for admission.
2.
______ I am currently considered an out-of-state student. I do not meet the guidelines for Alabama resident tuition but understand I
can apply for in-state tuition once I have met the guidelines outlined in Alabama Community College System Policy 803.01. I understand
that an in-state tuition request cannot be granted for a term that has already ended. An out-of-state student cannot attain residency
status by attending a college or university for 12 months in the state of Alabama.
3.
______ I qualify for in-state tuition rates because I reside in one of the following Tennessee counties (circle one): Bedford, Coffee,
Franklin, Giles, Lawrence, Lincoln, Marion, Marshall, Maury, Moore, or Wayne
4.
______ I have lived in the state of Alabama for less than 12 months. However, I certify that I have more substantial connections with
the state of Alabama than with any other state.
If #4 is selected, you may be eligible to pay the in-state tuition rate if at least ONE of the following applies to you. You are required to include
sufficient evidence to the Office of Admissions & Records along with the Signature Page for consideration of in-state tuition classification.
1. Payment of Alabama state income taxes as a resident
2. Ownership of a residence or other real property in the state and payment of state ad valorem taxes on the residence or property
3. Full-time employee of Calhoun Community College (self, spouse, or supporting person)
4. Full-time employment in the state within 90 days of registration (self, spouse, or supporting person)
5. Member of the United States military on full-time active duty stationed in Alabama (self, spouse, or supporting person)
6. Accredited member of a consular staff assigned to duties in Alabama (self, spouse, or supporting person)
By signing below, I certify that all information is accurate. I understand that falsification of information could result in dismissal or
disciplinary action.
Signature of Student: ____________________________________
Date: ___________________
FOR OFFICIAL USE ONLY
According to Alabama Community College System Policy 801.01: Admission: All students must provide one primary form of identification in order
to be eligible for admission to an Alabama Community College.
Type of Identification: ____________________________
Issue Date: ___________
Student’s DOB: ____________
Expiration Date: __________
Signed: _______________________________________________
College Official
Date: ________________________________
FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA) – BUCKLEY AMENDMENT
NOTICE: Under the Federal Family Educational Rights and Privacy Act 20 U.S.C. 1232g, Calhoun Community College may disclose certain student information to individuals
and/or agencies, institutions, etc. as directory information. The College does not provide mailing lists unless required to do so by federal legislation, a court directive, or as
deemed appropriate by the President of the college or his agent. Calhoun Community College considers the following to be directory information as defined by the college
catalog: name, address, telephone listing, email address, date and place of birth, major field of study, dates of attendance, enrollment status, class standing, degrees, honors,
and awards received, and the most recent educational agency or institution attended. If any student objects to the aforementioned information being released, the student
should visit the Office of Admissions & Records on either the Decatur or Hunstville Campus to file a DO NOT RELEASE form.
ACCELERATED HIGH SCHOOL STUDENT PROGRAM
CERTIFICATION FORM
Admissions Office
P.O. Box 2216 • Decatur, AL 35609-2216
205/306-2500 or 1-800-626-3628
Studentʼs Name __________________________________________ Social Security Number ______ - ______ - _______
High School______________________________________________
This is to certify that the above named student has completed the 10th grade, has at least a cumulative "B"
average and is recommended for participation in the accelerated High School Program at Calhoun
Community College. Approval from secondary school officials indicates that the student has
demonstrated both academic readiness and social maturity.
_____________________________________
Principal or his/her designee
NOTE:
The student may enroll only in postsecondary courses for which high school prerequisites have
been completed. (For example: a student may not take English Composition until all required
high school English courses habe been completed.) A certification form must be submitted for
each term of enrollment.
It is the official policy of the Alabama State Department of Education, including Postsecondary institutions under the control of the State Board of Education, that no person in Alabama shall, on the grounds of race,
color, disability, sex, religion, creed, national origin, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program, activity, or employment.
4/16
DualEnrollment/AcceleratedHighSchoolProgram
RegistrationForm
Incomplete registration forms, library or parking fines, Business Office or Financial Aid holds and non‐compliance with the transcript policy will prohibit registration. A student’s status must be clear in order to register for classes. Each student is responsible for meeting all prerequisites for the courses for which he or she registers. Final decision about the transfer of courses will be made by the transfer institution. Student Name: ________________________________________________________________________ (First) (Middle) (Last) Student C #: _______________________________________________ Student SSN: _______________ ‐ ____________ ‐ _________________ Academic Program: DUAL ENROLLMENT or ACCELERATED HS Student Program High School: __________________________________________________ Semester: _______________________ Year: _________________ Course Registration Information:
CRN Course Name & Number Section ______________________________________ STUDENT SIGNATURE
Days Times Location ______________________________________
PAYMENT METHOD
___________________________________ DATE
Instructor ______________________________________ PAYMENT DUE DATE
NOTE: My Signature signifies I have read the information on this form and I have met all required Pre‐Requisite Score and Administrative Requirements for the courses in which I am enrolling, as listed above. Please consult your high school administrator to confirm applicable credit per your school and future transfer requirements. Unmet pre‐requisite scores and administrative requirements could result in disqualification from participating in the dual enrollment program.
Office Use ONLY: Processed by: ______________ Date Processed: __________ FamilyEducationRights&PrivacyAct
(FERPA)ReleaseAuthorization
The Family Education Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of student education records, both financial and academic. For the student’s protection, FERPA limits release of student record information without the student’s explicit written consent. I, Full Name Student ID/SSN Hereby authorize Calhoun Community College to release information concerning my academic records to the following individuals: NAME RELATIONSHIP Authorized documents include (but are not limited to):  Class schedule
 Transcripts
 Academic Standing
 Dates of Enrollment
 Hours/Classes Completed
 GPA (Grade Point Average)
 Transfer Credit
STUDENT SIGNATURE DATE **A PICTURE ID IS REQUIRED WHEN SUBMITTING THIS REQUEST** OFFICE USE ONLY RECEIVED BY DATE