First Come First Served – Payment due one week prior to start of class.

Please call 217-641-4207 to pay by credit or debit.

Submit form in through High School Counselor

SMART START - Concurrent Enrollment Spring 2015

Application and Course Registration

(Please PRINT and fill out COMPLETELY - Return form to JWCC Enrollment Services)

NAME______

Last First Middle Initial

Address______

Student Email______

Phone______Gender: Male q Female q

SSN |__|__|__| - |__|__| - |__|__|__|__| Date of Birth ______

(Social Security Number)

Please check online at jwcc.edu to see a full listing of course offerings.

Check
Course / CRN / Course Prefix / Course No. / Instructor Name / Attending Center / JWCC Course / Est Cost / CREDIT
HOURS
Selection
61170 / BUS / 101 ITD / LUNT / ONLINE / INTRO TO BUSINESS / 3
61179 / CSC / 106 ITB / STAFF / ONLINE / INTRO TO COMPUTERS / 3
61194 / ENG / 101 ITB / STAFF / ONLINE / RHETORIC & COMPOSITION I / 3
61198 / ENG / 102 ITB / STAFF / ONLINE / RHETORIC & COMPOSITION II / 3
61220 / HIS / 102 ITA / TERHUNE / ONLINE / WESTERN CIVILIZATION II / 3
61223 / HIS / 122 ITA / BERQUIST / ONLINE / US HISTORY II / 3
61235 / MAT / 109 ITA / KNAPP / ONLINE / ELEMENTARY STATISTICS / 3
61238 / MAT / 113 ITA / KNAPP / ONLINE / COLLEGE ALGEBRA / 3
61244 / MUS / 102 ITB / MACC / ONLINE / INTRO TO MUSIC / 3
61251 / PHL / 201 ITB / FODOR / ONLINE / MAJOR WORLD RELIGIONS / 3
61253 / PSC / 101 ITA / RODRIGUEZ / ONLINE / AMERICAN GOVERNMENT / 3
61256 / PSY / 101 HIM / BATTERTON / ONLINE / INTRO TO PSYCHOLOGY / 3
61270 / RST / 101 ITB / FODOR / ONLINE / INTRO TO THE BIBLE / 3
61274 / SOC / 101 ITA / MACC / ONLINE / INTRO TO SOCIOLOGY / 3
61278 / SOC / 111 ITB / DITTMER / ONLINE / SOCIAL PROBLEMS / 3
61240 / MFG / 101 ITA / FUHRMAN / ONLINE
March 16 – May 14 / MANUFACTURING PROCESSES AND PRODUCTION / 2
61239 / MFG / 102 ITA / FUHRMAN / ONLINE
January 12 – March 6 / INTRO TO MANUFACTURING/SAFETY / 2

Students are responsible for tuition and fees associated with the classes ($142 per credit hours tuition fee; online courses $30 per credit hour in addition to tuition fee). 217-641-4207.

Books for classes can be purchased through the JWCC Bookstore. Please Call 217-641-4230.

Have you ever attended John Wood Community College (including dual credit courses) q yes q no

High School attending ______ High School Anticipated Graduation Date______

Please identify your primary racial/ethnic group. (select only one)

Asian American Indian or Alaskan Native Black or African American Hispanic or Latino

White Native Hawaiian or Pacific Islander Choose not to respond/Unknown

Are you Hispanic or Latino? (Or are you of Spanish origin?)

Yes, I am Hispanic or Latino No, I am not Hispanic or Latino

Are you from one or more of the following racial groups? (select all the apply)

Asian American Indian or Alaskan Native Black or African American

White Native Hawaiian or Pacific Islander Choose not to respond/Unknown

Are you in the United States on a Visa?

No, I am a citizen of the United States

No, I am not a citizen of the United States, but am a legal resident alien or refugee - Resident #______

Yes, I am in the United States on a Visa Home Country of Origin:______Visa Type:______

Have you ever been a part of a TRIO program?

Upward Bound Educational Talent Search Other Not Applicable

Have either parent attended college? Yes No Have either parent completed a 4-year degree? Yes No

FERPA, the Family Educational Rights and Privacy Act of 1974, protects the privacy of student educational records. To authorize the release of this protected information (grades, academic records, bill information) the student must indicate they agree to the release.

High School (transcript/academic discussion) Parent – Tuition Bill discussion No I do not release information

______

Student’s Signature Date

______

Parent’s Signature Date

______Phone #______

Parent Name (print)

______Phone #______

High School Counselor Signature

Office of Admissions 1301 South 48th Street Quincy, IL 62305

Phone: 217.641.4337 fax: 217.221-0778