Please mail completed application to:

Central Washington University

Running Start Program

400 East University Way

Ellensburg WA 98926-7433

CWU ID

______

PERSONAL INFORMATION Male  Female

Circle: What year are you in high school now? Sophomore Junior Senior Circle: Term applying for: Fall Winter Spring

Have you earned college credit through CWU or any other institution? No Yes- Please list______

Public high school you will be enrolled in during Running Start: ______

Last Name ______First Name______Middle Name______

Social Security Number ______- ______- ______

Mailing Address ______

Number and Street / PO Box Apt.# City State Zip Code

Telephone (_____) ______Student Cellular Telephone (_____) ______

Student Email * ______* upon admission students must create an CWU email account

Date of Birth ______Birth place ______

Month Day Year City State Country (if other than U.S.)

______

ETHNICITY (OPTIONAL) (Required for State and Federal Statistics and requested on a voluntary basis. Answers will remain confidential)

White Black/African America American Indian or Alaska Native -Name of enrolled or principal tribe ______

Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Pacific Islander

No, not Spanish/Hispanic/Latino Yes, Mexican or Mexican American (Chicano) Yes, Puerto Rican Yes, Cuban Yes, other Spanish/Hispanic/Latino

______

FAMILY INFORMATION

INFORMATION FROM EDUCATIONAL RECORDS (DISCLOSURE AND CONSENT)

The Federal Educational Privacy Act (FERPA) restricts disclosure of educational records

I consent to the disclosure of my educational records by Central Washington University, which contains information pertaining to my enrollment in University courses and my academic progress in those courses as provided in this consent.

Information may be disclosed to my parents or guardians and appropriate high school and high school district officials for the following purposes:

·  To inform them of the potential costs associated with enrollment in University courses when they may be financially responsible.

·  To inform them of my progress towards high school graduation (Information could include: grades, student account information, fees, payments, and academic record information etc.)

Student Signature______Date______

This release will be on file the entire length of time you are a CWU Running Start student. Please notify our office in writing if any names listed on the front page are no longer eligible to receive information outlined above.

RUNNING START FUNDING LIMITS

The student is responsible (not the high school or college) for maintaining

a schedule that stays within the Running Start funding limits or the student

agrees to pay all university costs incurred for exceeding the funding limit.

If the student enrolls for more university credits than allowed according

the Running Start Funding Limit Table, the student is responsible for:

·  Paying all university costs associated with exceeding the limit

·  Withdrawing from the excess university or high school course(s)

We (Student and Parent) acknowledge, with our signatures below, that we have read, understand and will comply with the conditions of Running Start participation and the expectations of university course enrollment.

Student / Parent
Date______
Student Signature______
Student Printed Name______/ Date______
Parent Signature______
Parent Printed Name______

Disability Accommodations & Disclosure: Postsecondary education institutions may set their own requirements for disabilities documentation so long as they are reasonable and comply with Section 504 and Title II. It is not uncommon for documentation standards to vary from institution to institution. A student must provide documentation, upon request, that he or she has a disability, that is, an impairment that substantially limits a major life activity and that supports the need for an academic adjustment. Institutions of postsecondary education are not required to conduct or pay for an evaluation to document a student’s disability and need for an academic adjustment. An IEP or Section 504 plan is generally not sufficient documentation to support the existence of a current disability and need for an academic adjustment from an institution of postsecondary education.

CWU provides equal opportunity in education without regard to race, color, creed, religion, national origin, sex, age, marital status, disability or status as disabled veteran or Vietnam-era veterans in accordance with institutional policies and applicable federal and state statutes and regulations