EmailMe Form - WBW College Credit Registration Form

All participants are able to benefit from a reduced tuition rate of $75 (the typical community college tuition for two credits is about $200). These credits are optional, and the $75 fee is in addition to your registration fee for the Business Week Program. These two college credits are earned by fully participating in any of our one-week programs (except Advanced Business Week). There will be no additional tests or written papers required. The grade will be “S” (satisfactory). Business Week will make the determination on each application for college credit whether or not that the student has satisfactorily participated in the program. If it is determined that a student has not completed the program outcomes successfully, the registration form and payment for college credit will be returned to the student.

These credits may also be recognized as elective credits at other colleges, however it is up to each student to identify if and how credits will transfer to their intended college.

STUDENT CONTACT INFORMATION

Last Name *

First Name *

Middle Initial *

Former name(s), if applicable

Street/Mailing Address *

City *

State *

Zipcode *

Day Phone *

### - ### - ####

Evening Phone *

### - ### - ####

Email Address *

Social Security Number *

DISCLOSURE STATEMENT: To comply with federal laws, we are required to ask for your Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN). We will use your SSN/ITIN to report Hope Scholarship/Life Time tax credit, to administer state/federal financial aid, to verify enrollment, degree and academic transcrip records and to conduct institutional research. If you do not submit your SSN/ITIN, you will not be denied access to the college; however, you may be subject to civil penalties (refer to Internal Revenue Service Treasury Regulation 1.60505-1(e)(4) for more information). Pursuant to state law (RCW 28B.10.042) and federal law (Family Educational Rights and Privacy Act), the college will protect your SSN for unauthorized use and/or disclosure.

STUDENT ENROLLMENT STATUS

Student Enrollment Status *

First Time Ever Enrolled at EdCC

Former Student at EdCC

Presently Enrolled at EdCC

What is your main long term goal for attending Edmonds Community College? *

Take courses related to current or future work (11)

Transfer to a four-year college (12)

High School Diploma or GED (13)

Explore career direction (14)

Personal enrichment (15)

WBW Program *

These questions are to be completed by new students or returning students who have not attended EdCC in the last four quarters.

Birthdate *

MM / DD / YYYY

Gender *

Female

Male

Were you claimed for federal tax purposes by your mother, father or legal guardian in the current calendar year? *

Yes

No

Were you claimed for federal tax purposes by your mother, father or legal guardian in the past calendar year? *

Yes

No

If YES, how long has your mother, father or legal guardian lived continuously in the state of WA?

Years

Months

Have you been a resident of Washington State for the last 12 months? *

Yes

No

How long have you lived continuously in Washington State?

Years

Months

Military

Are you active duty military? *

Yes

No

Are you the spouse or dependent of an active duty military person? *

Yes

No

If YES, when was the active duty military person stationed in Washington?

MM / DD / YYYY

Citizenship

Are you a U.S. Citizen? *

Yes

No

If you are NOT a U.S. Citizen, what is your immigration status?

Immigrant/Permanent resident (IM)

Refugee/Parolee/Conditional Entrant (RF)

VISA holder

Other/VISA Type (please explain)

If your visa type is B, F, J, M or TN you must have an ISS student type. If your visa type is A, E, G, H, I, K, L or R the Enrollment Services Office will assist you.

SCHOOLING

Last High School attended *

City and State *

Graduated? *

Yes

No

Years Attended *

example - 2009 / 2010 / 2011 / 2012

To *

Last college, voc/tech, university attended

City and State

Years Attended

To

Graduated? *

Yes

No

How long do you plan to attend Edmonds Community College? *

One Quarter (11)

Two Quarters (12)

Do not know (16)

What is your current work status while attending college? *

Full-time employment (12)

Part-time off-campus (13)

Not employed, but seeking employment (15)

Not employed, not seeking employment (16)

What is your prior level of education at entry to Edmonds Community College? *

Less than high school graduation (11)

GED (12)

High school graduate (13)

Some post high school, but no degree or certificate (14)

Certificate (less than two years) (15)

Associate Degree (16)

What was your family status when you started at Edmonds Community College? Were you... *

Single parent with children or dependents in your care (11)

A couple with children or other dependents in your care (12)

Without children or other dependents in your care (13)

PAYMENT INFORMATION

Your check or money order should be made out to Washington Business Week in the amount of $75.00 and mailed to the Business Week Office. Cash and credit cards are also accepted. Washington Business Week is not able to provide financial assistance for the college credit fee.

Payment *

Charge $75 to the credit card I used for my registration fee

I will call with a credit card number

I will mail a check or money order to WBW

I will bring payment to registration at the program

Other