Dual Enrollment Application
Cape Cod Community College
2240 Iyannough Road, West Barnstable, MA 02668
774-330-4992 www.capecod.edu
Semester: Fall 20___ Spring 20___ Summer 20___
Section 1: STUDENT INFORMATION
All information is required unless otherwise stated within this application. Please print.
Name:
Mailing Address: Student Cell Phone:
Gender: Male Female Non-Binary
Email Address: Date of Birth:
High School: Anticipated Date of Graduation:
Ethnicity (this question is optional):
The Ofce of Civil Rights directs us to gather, for reporting purposes only, the ethnic distribution of our students.
This information is condential and is not individually released. Please check all that apply:
a. Do you consider yourself to be Hispanic or Latino (i.e., Cuban, South or Central American, or of other
Spanish speaking culture or origin? Yes No
b. Select one or more of the following racial groups to describe yourself:
American Indian or Alaskan Native Asian Black/African American
Brazilian
Native Hawaiian or Pacic Islander White/Caucasian
Attended high school outside of United States
Bachelor or higher
HS Diploma/GED
Associate degree
Parent/guardian educational background:
Parent/guardian #1:
Parent/guardian #2:
APPLICATION FOR GRANT AW
ARD
This section is required for students interested in applying for financial assistance.
Students will not be considered for funding if left blank. Applying does not guarantee an award.
CCCC may have some limited funds from the Commonwealth Dual Enrollment Partnership and from the Cape Cod
Community College Whitehouse fund that can be used to help eligible students with the of one course. Eligible
students will have financial need, be a first generation college student (neither parent has a bachelor’s degree),
and/or be a member of an underrepresented group at CCCC.
Household Size and Income:
Family Size: ________ Please include yourself, parents/guardians and siblings that live with you.
Total Household Income (Gross): $__________________ $__________________ $__________________
Year or Month or Week
Last First Middle Initial
Street
Town/City State Zip
Attended high school outside of United States
Bachelor or higher
HS Diploma/GED
Associate degree
Dual Enrollment Application
Cape Cod Community College
2240 Iyannough Road, West Barnstable, MA 02668
774-330-4992 www.capecod.edu
Section 2 – STATEMENTS OF UNDERSTANDING
Student: If accepted into the Dual Enrollment program, I agree to adhere to all rules, regulations, and requirements
set by Cape Cod Community College and/or the Massachusetts Department of Higher Education. I understand
that CCCC reserves the right to disclose my status as a high school student to CCCC faculty members. I hereby
authorize Cape Cod Community College to release all correspondence regarding my enrollment in the Dual
Enrollment program to my high school and to forward an ofcial report of my grades to my high school.
I understand that course-related costs including tuition, fees, and textbooks are not covered under the Dual
Enrollment Program. I understand that I must meet with a Dual Enrollment Counselor to register for my classes
and that I cannot drop a class or withdraw from a class without first meeting with a Dual Enrollment Counselor.
Signature of Student:
Date:
Parent/Guardian: I hereby grant permission for my child to apply to the Dual Enrollment Program at Cape Cod
Community College. Should my child be accepted, I grant permission for him/her/them to enroll in courses at the
College. I understand that course-related costs including tuition, fees, and textbooks are not covered under the
Dual Enrollment Program. I understand that my student’s CCCC academic records will be released to his/her/
their high school for inclusion in his/her/their school records.
Parent/Guardian Name (please print):
Signature:
Emergency Contact:
Date:
Emergency Phone:
Semester: Fall 20___ Spring 20___ Summer 20___
Section 3 – GUIDANCE
Please schedule an appointment to meet with your school counselor and discuss your Dual Enrollment options/
requirements. This entire page must be completed by a school official.
Student’s Name: SASID:
(required)
Cumulative high school GPA*: Expected Year of Graduation:
*A high school transcript must accompany this application
*Written recommendation must accompany this application if GPA is below 2.5
Minimum number of courses student may take at CCCC this semester:
Maximum number of courses student may take
Is the student eligible for free/reduced school lunch? Yes No
Please assist the above-named student in
lling out the table below by making specic course recommendations.
To ensure appropriate course selections, students will not be registered for dual enrollment courses without school
official consent, appropriate college placement test scores (if applicable), and completion of all course pre-requi-
sites (if applicable).
Course offerings can be found on CampusWeb by following this link: www.capecod.edu/courses
Contact Dual Enrollment with questions – 774.330.4992
Subject Fall Spring Summer
English
May consider Q Term/Accelerated Course
Recommended
Required
Recommended
Required
Recommended
Required
Math
May consider Q Term/Accelerated Course
Recommended
Required
Recommended
Required
Recommended
Required
Science
May consider Q Term/Accelerated Course
Recommended
Required
Recommended
Required
Recommended
Required
History
May consider Q Term/Accelerated Course
Recommended
Required
Recommended
Required
Recommended
Required
Elective
May consider Q Term/Accelerated Course
Recommended
Required
Recommended
Required
Recommended
Required
To ensure appropriate course selections, students will not be registered for dual enrollment courses without
school official consent, appropriate college placement test scores (if applicable), and completion of all course
pre-requisites (if applicable).
Comments from Counselor:
School Official Signature: Date:
School Official Name (Print):
Phone Number: Email address:
High School Counselors may submit completed application and current high school transcript by email to:
cocampbell@capecod.edu
can consider Q Term/
Accelerated Course
Certification of Information
I certify that this information is true and accurate. I understand that any misrepresentation, omission, or incorrect
information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.
Applicant Signature: Date:
Parent/Guardian Signature: Date:
(Applicant is under 18 years old)
For Official Use Only – Do not write in this box
I have reviewed the above information to determine this person’s eligibility to receive the in-state tuition rate.
Based on my review, I have determined that this individual
IS eligible for the in-state tuition rate.
IS NOT eligible for the in-state tuition rate.
I am unable to make a determination at this time. The following information has been requested
from the applicant:
Authorized College Personnel: Date:
MASSACHUSETTS COMMUNITY COLLEGES – IN-STATE TUITION ELIGIBILITY FORM
Last Name: First Name: MI:
SSN#: Date of Birth:
Are you a U.S. Citizen? Yes No
If not, please complete the following:
Are you a Permanent Resident? Yes No (If yes, list Alien Registration Number) :
If you are not a US Citizen or Permanent Resident, please state your Visa or Immigration status in detail:
Please check the in-state or reduced tuition eligibility category that applies to you:
I have been a Massachusetts resident for six (6) continuous months and intend to remain here.
As proof of my intent to remain in Massachusetts, I possess at least two (2) of the following documents, which
I shall present to the institution upon request. These documents* are dated with in one (1) year of the start date
of the academic semester for which I seek to enroll (except possibly for my high school diploma). The institution
reserves the right to make any additional inquiries regarding the applicant’s status and to require submission of
any additional documentation it deems necessary. Please check off those documents you possess as proof of your
intent to remain in Massachusetts.
Valid Driver’s license
Valid car registration
Mass. High School Diploma
Record of parents’ residency for unemancipated
person
I am an eligible participant in the New England
Board of Higher Education’s Region al Student
Program.
I am a member of the Armed Forces
(or spouse or unemancipated child) on active
duty in Massachusetts.
Utility bills
Voter registration
Signed lease or rent receipt*
Employment Pay Stub
State/Federal tax returns*
Military home of record
Other
