Online Student Application

1. Start Term *: Select One 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Spring
   Note: Select when you would like to start your services.
2. Expected Graduation Term: Select One 2014 - Summer 2014 - Fall 2015 - Spring 2015 - Summer 2015 - Fall 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Spring
   Note: Select when you plan to graduate.
3. First Name *:
4. Last Name *:
5. Middle Name:
6. Optional: Preferred Name:
7. JWCC ID *:
   For Example: J00000000
8. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
9. Gender *: Select One Female Male Not Specified
10. Pronouns: Select One he, him, his, his, himself per, per, pers, pers, perself she, her, her, hers, herself they, them, their, theirs, themself ve, ver, vis, vers, verself zie, hir, hir, hirs, hirself

1. Primary Phone Number:
   Hint: Enter 10-digit number only.
2. Secondary Phone Number:
   Hint: Enter 10-digit number only.
3. Email Address *:

1. Address *:
2. City *:
3. State *: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode *:
   Hint: Enter zipcode as 97331 or 97331-0000.

Same as Local Address

1. Address:
2. City:
3. State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode:
   Hint: Enter zipcode as 97331 or 97331-0000.

1. Primary Disability *: Select One === 0200 Blind/Low-vision === 0201 Blind 0202 Low-vision === 0800 Mobility === 0801 Amputee (no wheelchair) 0802 Amputee (with wheelchair) 0803 Cerebral Palsy (no wheelchair) 0804 Cerebral Palsy (with wheelchair) 0805 Neuromuscular Disease (no wheelchair) 0806 Neuromuscular Disease (with wheelchair) 0807 Orthopedic (no wheelchair) 0808 Orthopedic (with wheelchair) 0809 Osteogenesis Imperfecta (no wheelchair) 0810 Osteogenesis Imperfecta (with wheelchair) 0811 Repetitive Stress (no wheelchair) 0812 Repetitive Stress (with wheelchair) 0813 Spina Bifida (no wheelchair) 0814 Spina Bifida (with wheelchair) 0815 Spinal Cord Injury (no wheelchair) 0816 Spinal Cord Injury (with wheelchair) 0890 Other (no wheelchair) 0891 Other (with wheelchair) === 0900 Psychological === 0901 Anxiety Disoder 0902 Asperger's 0903 Autism 0904 Bipolar Disorder 0905 Depressive Disorder 0906 Personality Disorder 0907 Schizophrenia/Schizoaffective Disorder 0908 Sleep Disorder 0990 Other Psychological === 1100 Systemic/Chronic Health === 1101 Allergies 1102 Cancer 1103 Cardiac 1104 Diabetes 1105 Hematological Disease 1106 HIV/AIDS 1107 Inflammatory Diseases 1108 Respiratory 1109 Seizure Disorder 1110 Alcoholism/drug dependency 1190 Other Health === General Category === Other
2. Secondary Disability(ies)

   0200 Blind/Low-vision

   0201 Blind

   0202 Low-vision

   0800 Mobility

   0801 Amputee (no wheelchair)

   0802 Amputee (with wheelchair)

   0803 Cerebral Palsy (no wheelchair)

   0804 Cerebral Palsy (with wheelchair)

   0805 Neuromuscular Disease (no wheelchair)

   0806 Neuromuscular Disease (with wheelchair)

   0807 Orthopedic (no wheelchair)

   0808 Orthopedic (with wheelchair)

   0809 Osteogenesis Imperfecta (no wheelchair)

   0810 Osteogenesis Imperfecta (with wheelchair)

   0811 Repetitive Stress (no wheelchair)

   0812 Repetitive Stress (with wheelchair)

   0813 Spina Bifida (no wheelchair)

   0814 Spina Bifida (with wheelchair)

   0815 Spinal Cord Injury (no wheelchair)

   0816 Spinal Cord Injury (with wheelchair)

   0890 Other (no wheelchair)

   0891 Other (with wheelchair)

   0900 Psychological

   0901 Anxiety Disoder

   0902 Asperger's

   0903 Autism

   0904 Bipolar Disorder

   0905 Depressive Disorder

   0906 Personality Disorder

   0907 Schizophrenia/Schizoaffective Disorder

   0908 Sleep Disorder

   0990 Other Psychological

   1100 Systemic/Chronic Health

   1101 Allergies

   1102 Cancer

   1103 Cardiac

   1104 Diabetes

   1105 Hematological Disease

   1106 HIV/AIDS

   1107 Inflammatory Diseases

   1108 Respiratory

   1109 Seizure Disorder

   1110 Alcoholism/drug dependency

   1190 Other Health

   General Category

   Other
3. Other Disability or Note:
4. Seeking Degree: Select One Associate in Applied Sciences Associate in Arts Associate in Science Certificate Dual Credit Dual Enrollment
5. Major: Select One ABFC Beef Specialist Certificate ACCA Accounting - AA degree ACCT Accounting - Certificate ACCV Accounting - AAS degree AES Associate Engineering Science AFAM Music Performance Option AGR Agriculture - AS degree AGRA Agricultural Applications Certificate AGRM Agricultural/Bus Management - AAS degree ART Art - AA degree ASC Animal Science - AAS degree BIO Biology - AS degree BMA Business Management - AAS degree BMGT Business Management Certificate BUSA Business - AA degree CAD Computer Aided Design - AAS degree CHD Early Childhood Education - AAS degree CHM Chemistry - AS degree CIS Business Computer Information - AAS degree CMAC Certified Medical Assistant Certificate CMN Communications - AA degree CNS Computer Network Support - Certificate CSCA Computer Science - AA degree DET Diesel Technology Certificate DPC Desktop Publishing Certificate ECOA Economics - AA degree EDSW Engineering Design - Solid Works - Certificate EDU Education - AA degree EGR Engineering - AS degree ELE Electrical Technology - AAS degree ELEC Electrician - Certificate EMS Paramedicine - AAS degree EMSP Paramedic - Certificate ENG English - AA degree FSC Fire Science - AAS degree GPDS Graphic Design - AAS degree HADN Health Services ADN - AS degree HCA Healthcare Assistant Program - Certificate HIS History - AA degree HPR Physical Education - AS degree HSUR Health Services SUR - AS degree IMT industrial Maintenance Technology - AAS degree IMTE Industrial Tech Electrical - Certificate IMTM Industrial Tech Mechanical - Certificate LAR Liberal Arts - AA degree LENA Law Enforcement - AA degree LEND Law Enforcement - AAS degree LOG Logistic/Operations Management - AAS degree LOGC Logistics Certificate LOGT Truck Driving Training - Certificate MAT Mathematics - AS degree MCNC Precision Machining Machinist - Certificate MCPT Certified Production Tech - Certificate MED Medical Lab Tech - AAS degree MFT Manufacturing Technology - AAS degree NUA Nursing Assistant - Certificate NUAP Professional Nursing Assistant - Certificate NUR Associate Degree Nursing (ADN) - AAS degree OFT Office Technology - AAS degree OFTB Office Technology - Certificate OFTM Office Technology: Medical - AAS degree OFTN Medical Office Certificate PHY Physics - AS degree PNU Practical Nurse - Certificate PSC Political Science - AA degree PSY Psychology - AA degree RAD Radiologic Tech - AAS degree SCMA Supply Chain Management - AA degree SOC Sociology - AA degree SURD Surgical Technology - AAS degree SWSC Swine Specialist Certificate UND Undecided - AS degree UNDA Undecided - AA degree WEBC Web Design Certificate WLDC Welding Certificate WLDI Industrial Welding Certificate

Affiliation(s)

6. Affiliation(s)

   Athletes

   Department of Rehab Services (DORS) Funded

   Dual Enrollment

   TRIO Students

   Veterans

Ethnicity(ies)

7. Ethnicity(ies)

   1 Black or African-American

   2 American Indian or Alaskan Native

   3 Asian

   4 Hispanic

   5 White

   6 Native Hawaiian or Pacific Islander

   7 Choose not to respond/Unknown

Campus Location(s)

8. Campus Location(s)

   Agricultural Education Center

   Blessing Hospital

   Learning Center

   Mt. Sterling Learning Center

   Paul Heath Community Education and Fine Arts Center

   Pittsfield High School

   Quincy Area Vocational Technical Center

   Quincy Regional Fire Training Facility

   Science & Technology Center

   Southeast Education Center

   Student/Administration Center

   Workforce Development Center
9. Additional Note: