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QUINEBAUG VALLEY COMMUNITY COLLEGE

APPLICATION FOR ADMISSION

Find the student type that best describes you, then follow the easy steps to enroll at QVCC. In order to complete your application file and register for courses, you must submit all required documents.

NEW

First time college student

Complete the Application for Admission and submit it with the $20.00 application fee. Submit proof of high school completion or GED completion (diploma or transcript). Transcript is recommended.* Submit immunization records for measles, mumps, and rubella if you were born after 1956 (waived for graduates of a Connecticut high school in 1999 or later or if a first time non-degree student enrolled for less than 12 credits). Submit immunization records for varicella (chicken pox) if you were born after January 1, 1980. Please note there are NO waivers for graduation from a CT high school. After receipt of your application, information will be sent to you about arranging the computerized Basic Skills Assessment (BSA) required of all students prior to enrollment. If you have taken the SAT, the BSA may be waived when the English SAT writing and/or reading score is 450 or above and/ or math score is 550 or above. A Waiver Request form must accompany SAT score documentation.

* Students 16 years of age and under, students without a diploma or GED, and home-schooled students may have additional requirements. Please call for information.

TRANSFER Have attended another college prior to enrollment at QVCC

Complete the Application for Admission and submit it with the $20.00 Application Fee (if you applied to another CT community college, this fee is waived). Submit proof of high school completion or GED completion (diploma or transcript). Submit immunization records for measles, mumps, and rubella if you were born after 1956 (waived for graduates of a Connecticut high school in 1999 or later, or if a first time non-degree student enrolled for less than 12 credits). Submit transcripts of previous course work to determine if computerized Basic Skills Assessment (BSA) can be waived. If you are in a degree/certificate program and need an official transfer evaluation: Submit QVCC Transfer Credit Evaluation Request Form. Request an official transcript(s) from previous college(s) to be sent to QVCC Admissions office.

RE-ADMIT Haven't attended QVCC in two or more years

Submit Readmit Application available at the Student Services/Learning and Student Development Office in Danielson or at the front desk at the Willimantic Center. Please call the Admissions office to verify that we have all the records needed for you to register including: · Proof of high school or GED completion. · Measles, Mumps, Rubella and Varicella immunization records · Basic Skills Assessment results or completed math and English courses.

MAIN CAMPUS 742 Upper Maple Street, Danielson, CT 06239 · (860) 412-7200 · Fax (860) 412-7222 WILLIMANTIC CENTER 729 Main Street, Willimantic, CT 06226 · (860) 423-1824 · Fax (860) 423-4625

www.QVCC.commnet.edu

DEGREE & CERTIFICATE PROGRAMS

· You will need to enter the Program Name and Code of the Degree or Certificate you wish to pursue on page 4 of the application. · If you are not planning to pursue an Associate Degree or Certificate program at this time enter "Non-degree/nonmatriculated" (L15LZ99). All Summer Session applicants will be coded as "Non-degree/Summer only" (L15LZ98) . · If you are undecided of your choice, please use the code for General Studies.

ASSOCIATE DEGREES

Program Accounting Aviation Maintenance BOT: Administrative Assistant Computer Networking Computer Services (all tracks) Early Childhood Education Engineering Science Fine Arts ­ Graphic Arts Option ­ Photography Option ­ Studio Art Option ­ Graphic Design Option General Studies Code L11LA03 L11LA30 L11LA46 L11LA04 L11LA53 L11LA05 L11LA35 L12LA36 L12LA20 L12LA32 L12LA33 L12LA34 L11LA39 Human Services Program Liberal Arts & Sciences Management Medical Assisting Pathways to Teaching Careers Technology Studies ­ Biomolecular Science Option ­ Computer Aided Design Option ­ Construction Technology Option ­ Engineering Technology Option ­ Lean Manufacturing & Supply Chain Management Option ­ Plastics Option L11LA40 Code L12LA43 L11LA68 L11LA45 L12LC35 L11LF11 L11LF21 L11LF15 L11LA70 L11LF12 L11LF20 L11LA56

CERTIFICATES

Program

Code

Program Early Childhood Education Graphic Arts Health Career Pathways HIMT: Coding Specialist Lean Manufacturing Microcomputer Software Applications Microcomputer Software Fundamentals Patient Care Technician Phlebotomy Photography Plastics Technology Senior Network Specialist Studio Art Supply Chain Management

Code L13LJ02 L13LJ50 L13LK55 L13LJ21 L13LN13 L13LJ24 L13LJ25 L13LJ01 L13LJ35 L13LJ51 L13LJ29 L13LJ04 L13LJ52 L13LN14

Advanced Accounting L13LJ39 Advanced Management L13LJ41 Applied Accounting L13LJ38 Applied Management L13LJ40 Arts Entrepreneur L13LJ45 Associate Network Specialist L13LJ44 BOT: Medical Office Skills L13LJ43 BOT: Medical Secretary L13LJ23 BOT: Office Skills Update L13LJ28 BOT: Secretarial L13LJ26 Child Development Associate Preparation L13LJ03 Community Health Worker L13LJ46 Computer Services: Technical Support L13LJ36 Construction Technology L13LJ47 Criminal Justice L13LJ05

Affirmative Action/Equal Opportunity

Quinebaug Valley Community College adheres to the principles of affirmative action/equal opportunity in admission and employment. The College does not discriminate against any individual on the grounds of race, color, religious creed, sex, age, national origin, ancestry, present or past history of mental disability, genetic information, marital status, mental retardation, sexual orientation, learning disability, or physical disability including, but not limited to, blindness, political beliefs, veteran status, or prior conviction of a crime, unless the provisions of section 46a-60(b), 46a-80(b), or 46a-81(b) of the Connecticut general statutes are controlling.

QUINEBAUG VALLEY

COMMUNITY COLLEGE

A $20.00 non-refundable application fee is required, except for those applicants who have previously attended a Connecticut Community College. Please submit a copy of high school diploma or GED.

For Office use only

Date__________________________

APPLICATION FOR ADMISSION

BANNER @ Received _____________ Entered _____________________ Entered by _________________________________________ Admit Type _____________ Student Type ________________ Ability to Benefit met _____ Yes _____ No Application Fee paid _____ Yes _____ No Cash ____ Check #____________ Waived ______________ Credit Card ______________ Deferred __________________

(First) (Middle)

Applicant's Legal Name

(Last)

Former Last Name(s)

-

-

/

/

(Gender: M/F)

(Social Security Number)

(Date of Birth)

(Social Security Number is requested for purposes of financial aid, Federal income tax benefits, the provision of some College services, accuracy of student records and other business purposes.)

Mailing Address

Street City City Work State State Cell Zip Zip

Permanent Address

Street

Telephone

Home

E-mail

(used for correspondence from the College)

Have you ever attended this college? Yes No If yes, when? ________________________________________________ Have you previously attended a CT Community College? Yes No If yes, where?________________________________ For which semester are you applying? Fall (Sept-Dec) Spring (Jan-May) Winter (Dec-Jan) Summer (Jun-Jul) Year____ CITIZENSHIP

Are you a United States citizen? Yes No If no, are you a Permanent Resident? (Green Card holder) Yes No

ETHNICITY/ RACE

Please provide the following ethnicity and race data. This information is requested on a Voluntary basis by the U.S. Department of Education, National Center for Education Statistics. Your answer will not affect admission to or registration in the college. Do you consider yourself to be Hispanic/Latino? What is your race? Select one or more: Yes No Asian(45) Other(90) Yes American Indian or Alaskan Native(50)

White(10) Black or African American(20) Native Hawaiian or Other Pacific Islander(80)

FAMILY EDUCATIONAL BACKGROUND

Do either of your parents hold a Bachelor's Degree (4-year College Degree) or higher? No

MILITARY STATUS

Are you currently on active duty with the U.S. armed forces? Yes No (ACTD) Are you currently a member of the National Guard or Reserve? Yes No (NGRE) Have you ever served in the U.S. armed forces? Yes No (VET1) Are you a dependent of a member of the U.S. armed forces? Yes No (VETD) If you answered "Yes" to any of these questions you may be entitled to benefits and you should meet with the College's Veterans Certifying Official (VCO).

IN-STATE TUITION

1. I am eligible for in-state tuition because I have continuously resided in Connecticut for at least one year and Connecticut is my permanent home. _____ Yes _____ No 2. Even though I answered "No" to the question above, I claim and can demonstrate through documentation that I am eligible for in-state tuition. _____ Yes _____ No Out-of-state students may be eligible for a reduced tuition rate through the NEBHE program. For details, see the college catalog or website. 3. ___ Check here if applying under the New England Regional Student program (NEBHE). If you answered "Yes" to question #2 or checked question #3, you must submit a "Declaration of Eligibility for In-State or NEBHE Tuition" for review and determination of eligibility.

DEGREE STATUS

In which Degree/Certificate program are you planning to enroll?_________________________________________________________________ Use list of majors/codes on back of application. Please write major name and code above.

HIGHEST DEGREE LEVEL (check one only)

No High School Diploma or GED(01) Undergraduate Certificate (05) Master's Degree (09) First Professional Degree (JD, MD, DDS, LLB) (12) High School Diploma or GED(02) Associate's Degree (07) Other Advanced Degree (10) Sixth-Year Certificate (13) Some College (06) Bachelor's Degree (08) Doctoral Degree (11)

EDUCATIONAL GOALS

Certificate (credit) (CT) Transfer without an Associate's Degree (DN) Associate's Degree (DG) Job Preparation/Retraining Course (JB) Developmental (College Preparation) Education (DV) Fulfill other college's requirement (AC) Job Promotion (JP) Transfer with an Associate's Degree (DT) Personal Development Course(s) (PD) Improve English Skills/Proficiency (ES)

Unsure at this time (UN) Other Goal (NL) _____

ACADEMIC BACKGROUND

Do you have a High School Diploma? Yes No Pending Graduation Year _____________________________________ Name of High School__________________________________Town_____________________________State_____Country _______________ Do you have a General Equivalency Diploma (GED)? Yes No Year______ GED Number________ Town/State __________________ Do you have an Adult High School Diploma? Yes No Graduation Year___________Town/State________________________________ Do you have a Home School Diploma? Yes No Graduation Year___________Town/State_____________________________________ Have you participated in the High School Partnership Program through the CT Community Colleges? Yes No Have you participated in the College Career Pathways/Tech Prep Program through the CT Community Colleges? Yes No

PREVIOUS COLLEGE BACKGROUND College/University Name State

Dates of Attendence

Graduation Date

Degree Awarded

_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ INTERNATIONAL STUDENT INFORMATION

Are you an International Student who needs an I-20 form for an F1 Visa? Visa Start Date_______________________________________ Yes No Other Visa Holder (indicate type)______________________________ Visa Admission Number ______________________________________ Visa End Date _____________________________________________ International Address _________________________________________________________________________________________________

EMPLOYMENT INFORMATION

Employed Full Time Employed Part-time Unemployed Yes No Name of Employer___________________________________Address of Employer_________________________________________________ Title/Position_______________________________________ Does your Employer have a Tuition Reimbursement Program?

E-MAIL COMMUNICATIONS

I request the College forward to me at the e-mail address I have provided all correspondence, including personally identifiable information pertaining to me from College records that are protected by FERPA.

Signature: _________________________________________________________ Date: _____________________________________

CONSENT FOR THE DISCLOSURE OF EDUCATION RECORDS

I understand that to maintain accurate student records, including the records pertaining to my attendance at the College, and for other necessary business purposes, the College may need to release or provide access to personally identifiable information in its records pertaining to me to another College in the Community College System or to the System's administrative office. Accordingly, I hereby authorize the College to release or allow access to such information to those indicated for the purposes described.

Signature: _________________________________________________________ Date: _____________________________________

I certify with my signature below that I am the applicant and that the information I have provided above is accurate. If admitted, I pledge to comply in good faith with all the rules and regulations of the College. I realize that any misleading information provided by me on this application may be cause for dismissal. I understand that information collected in this application is for reporting purposes only and will not be used in the selection process for admission.

Student Signature_________________________________________________________________________Date_______________________ Parent/Guardian Signature (if under 18)_______________________________________________________Date_______________________

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