High School Continuing Education Application - Edgecombe Community College

Name of Summer Program*

Program Start Date*

ECC Student ID Number

First Name*

Last Name*

Address*

City*

State*

Zip*

County of Residence*

Email Address*

Enter Email Confirm Email

Home Phone*

Work Phone

Cell Phone

Date of Birth*

Race*

Race Other

Gender*

Male
Female

Employment Status*

Are you a student who is currently enrolled in high school?*

Yes
No

High School

Highest completed level of education*

Citizenship*

US Citizen
Permanent Resident Alien
Alien Authorized to Work
Other

Citizenship Other

Name of Employer

Job Title

T-Shirt Size*

(Adult sizes)

How did you hear about this class?

Authorization

I grant permission to Edgecombe Community College to use my image and/or quotes for any use the college deems appropriate in the promotion and marketing of the college through print and electronic media. I also agree that the North Carolina Community College System my use my image and/or quotes to promote community college services throughout the state.
I hereby give permission to Edgecombe Community College and the NC Department of Community Colleges to release my grades/transcripts to the following credentialing agencies and affiliated chief officer of my agency/department: NC Department of Insurance Fire/Rescue Commission, NC Criminal Justice Training & Standards Commission, NC Sheriff’s Training & Standards Commission, NC Office of Emergency MEdical Services, Student’s Affiliated Agency/Department of Chief Officer (Written Request)

Guidelines for COVID-19 Symptoms or Positive Test*

Edgecombe Community College has established guidelines for COVID-19 symptoms or positive test. Please confirm you have reviewed these guidelines before submitting this form. View Guidelines

I confirm that I have reviewed these guidelines.

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