APPLY ONLINE at cty.jhu.edu/ctyonline
CTY Online Programs Application
PART I. Student Information
CTY students can find their Student ID above the name and address on the catalog, in
CTY email messages, or by contacting ctyinfo@jhu.edu or 410-735-6277. Students new
to CTY without a Student ID may apply and will be assigned a Student ID provided
they can establish eligibility according to cty.jhu.edu/ctyonline/apply/eligibility.
CTY Student ID:
Name
Last
Gender (check one):
First
M
F
Birth Date:
mm
/
MI
dd
/
yyyy
Optional: Race/Ethnicity (check one):
Native American or Alaskan Native
Asian or Asian American
White or Caucasian
Native Hawaiian or Pacific Islander
Other
Black or African American
Latino or Hispanic
American of South Asian Origin
PART II. Parent/Guardian Information (Required if a student has never taken a CTY course.)
Mother/Parent 1/Guardian
Father/Parent 2/Guardian
Name:
Name:
Email:
Email:
Employer:
Employer:
Position:
Position:
Work Phone Number: (
)
Work Phone Number: (
Cell/Other Phone Number: (
)
Cell/Other Phone Number: (
)
Home Phone Number: (
)
)
Home Phone Number: (
Home Address:
)
Home Address:
PART III. Student Address Information ( Any course completion documents will be sent to this address unless
you update by logging into MyCTY.)
Mailing Address:
Street, Route, or Box
City
Phone: (
)
State
Student Email:
Zip
(required)
Check here if you would prefer not to receive CTY news and updates via email.
Instructions for Submitting Application:
Applications for individually paced and flexi-paced courses will
be accepted at any time. Application deadlines for session-based
courses with specific start dates are available on the website;
however, students should apply early since classes may fill.
A complete application includes:
Program Application (Pages 1–4)
Signatures of student and parent or guardian
Copy of appropriate score report if not on file with CTY
Mail application with payment to:
CTY Online Programs
Johns Hopkins University
P.O. Box 64710
Baltimore, MD 21264
Or APPLY ONLINE at cty.jhu.edu/ctyonline
SUBMIT ONLY ONE APPLICATION. DUPLICATE
APPLICATIONS RESULT IN DUPLICATE CHARGES.
P
ayment in full OR
Financial aid application with tuition deposit
My financial aid application is attached (Form available at cty.jhu.edu/financial)
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Important: Your application cannot be processed without pages 1–4.
PART IV. Eligibility
Confirm that the student is eligible for the course before submitting this application. Check the eligibility chart on the website
and the course description in the catalog or on the website for prerequisites. Tuition will be refunded for applications
denied on the grounds of ineligibility, but the application fee is nonrefundable. Contact ctyonline@jhu.edu if you have questions.
Please enclose a copy of the student’s score report or other documentation unless the information is already in CTY records.
/
Name of test:
(SCAT/SAT/ACT/PSAT)
Reading/Verbal Scaled Score
STB Score (optional):
Quantitative Scaled Score
STB Test Date:
mm
/
Test Date mm/yy
Grade when Tested
yy
PART V. School Information
Grade:
as of
mm
School Address:
Type of School:
/
School Name:
yy
City
State
Public
Private/lndependent
Parochial
Home Schooled
Zip
School Phone: (
Country
)
PART VI. Course Request
Choose the course from the course catalog: cty.jhu.edu/ctyonline/courses
Check course descriptions for prerequisites and eligibility requirements.
Sample
If your course requires prerequisites, please explain how you met the prerequisites:
Name of
Course
4-Character
Course Code
Dragon Tales
Y Y DT
mm
Honors Algebra I
A L 1 Q
mm
Name of
Course
4-Character
Course Code
Session-Based
Start Date
Flexi-Paced
Start Date*
01 / 25 / 2016
dd
yyyy
/
mm
Individually Paced
Requested Start
Date*
/
dd
/
yyyy
mm
/
dd
yyyy
Leave blank for session or
flexi-paced courses
/
/
dd
/
yyyy
Session-Based
Start Date
/
mm
mm
/
yyyy
06 / 16 / 2016
yyyy
Flexi-Paced
Start Date*
/
dd
/
dd
mm
mm
/
yyyy
yyyy
Individually Paced
Requested Start
Date*
/
dd
dd
mm
/
dd
yyyy
* Allow approximately 2 weeks for processing.
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Important: Your application cannot be processed without pages 1–4.
PART VII. Tuition and Fees* (To be completed by parent or guardian.)
A. Student Name
Last
First
MI
CTY Student ID
* Tuition and fees are subject to change. See cty.jhu.edu/ctyonline/tuition for latest information.
B. Tuition and Fees
$ 15.00 Non-refundable application fee
$
Tuition for course
$
Tuition deposit for financial aid applicants*
$
International fee ($20 per course), required only for students outside the U.S.
$
Late fee ($25 per course) for session-based course applications submitted after the deadline, if applicable
$
Donation to help another student attend CTY (optional)*
$
Total payments included
My financial aid application is attached.
Note: Please see Financial Aid Policies and Procedures at cty.jhu.edu/financial
Please check the box on the bottom of page 1 indicating you are applying for financial aid.
* CTY is a self-supporting division of Johns Hopkins University (JHU), an accredited 501(c)3 not-for-profit organization. Your gift is tax-deductible
in accordance with federal, state, and local regulations. More information can be found at cty.jhu.edu/support.
C. Method of Payment
SUBMIT ONLY ONE APPLICATION. DUPLICATE APPLICATIONS RESULT IN DUPLICATE CHARGES.
CTY Online Programs
Johns Hopkins University
P.O. Box 64710
Baltimore, MD 21264
Dated
Check #
/
mm
/
dd
yyyy
Please include student’s name and CTY Student ID, if known, on the check.
Name of person signing check:
If
paying by e-check/credit card, mail application without payment information to our lockbox address above.
The payer noted below should call the CTY office during normal business hours, within 24-48 hours of submission of
the application at 800-393-6095 (select option #1) to provide payment information.
Payer Name:
Contact Phone Number: (
)
PLEASE DO NOT INCLUDE CREDIT CARD OR BANKING INFORMATION ON THIS FORM.
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Important: Your application cannot be processed without pages 1–4.
PART VIII. Signatures
We understand that consideration for this program is based on the student’s test scores. While enrolled, the student will follow the
guidelines and rules established for all aspects of the program, including the Student Code of Conduct, or may be withdrawn from
the program without refund. We have read and understand the refund policy.
We agree to CTY’s Privacy Policy (cty.jhu.edu/privacy).
I permit my child to complete all tests and surveys deemed necessary in evaluating program effectiveness. I also permit my child
to be interviewed for broadcast or publication, and/or have a sample of his or her work broadcast or published. I understand that
CTY will exercise discretion regarding media contact. In addition, I have reviewed the technical requirements if any (hardware
and software) for the requested courses. If required for the course, my child has access to a computer that meets specified
requirements. My child also has access to email.
We are responsible for full payment of all tuition and fees. Payments received with this application are applied to past due balances
first and then to the current application. Applications that do not meet CTY payment requirements will be returned. Application fees
are non-refundable.
Date
Signature of Student (Required)
/
mm
Date
Signature of Parent/Guardian (Required)
/
dd
/
mm
yyyy
/
dd
yyyy
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