Community College Access Program

Application for Current Program Participants

If you need assistance completing this application, please contact Carolyn Payne at cpayne@virginiawestern.edu or call 857-6371.

All fields are required unless otherwise indicated. Only complete this application if you attended Virginia Western Community College beginning Fall 2012 as a CCAP participant.

Application is due March 29, 2013.

Current Program Application

Applicant Information

Last Name:

First Name:

Middle Initial: (optional)

Emplid (required):

SSN:
A social security number is not required, but is highly recommended. If not given, access to some services will be limited, tax reporting information will not be available, and scholarship aid delayed. If you don't provide your SSN, you must provide an Emplid.

Date of Birth: MM/DD/YYYY

Street Address:

Mailing Address:
Same as Street Address

City:

State:

Zip Code:

Home Phone: XXX-XXX-XXXX

Cell Phone: XXX-XXX-XXXX

Email:

Parent or Guardian Information

Parent/Guardian
Last Name:

Parent/Guardian
First Name:

Relationship:

Street Address:

Mailing Address:
Same as Street Address

City:

State:

Zip Code:

Home Phone: XXX-XXX-XXXX

Cell Phone: XXX-XXX-XXXX

Email: (optional)

Current Program

What program are you currently participating in? City of Roanoke City of Salem Franklin County

Summer Courses

Will you enroll in the 2013 summer semester? Yes No

If yes, how many credits will you enroll in? Less than 6 credits
6 credits
More than 6 credits

CCAP funds will only pay for a maximum of 6 non-developmental credits during the 2013 summer semester.

Certification

By checking each box below, I certify that my parent/guardian and I understand each item:

	1. I have read and understand the rules, guidelines, and performance/ accountability criteria for CCAP.
	2. Based on the program I am applying for, I authorize Virginia Western Community College to release program information, photography, and any pertinent directory information to the media and/or the City of Roanoke, City of Salem, or Franklin County.
	3. I understand that I must complete and submit the Free Application for Federal Student Aid (FAFSA) and CCAP application by March 29, 2013 so that a determination can be made regarding eligibility for financial assistance.
	4. I understand CCAP is a private/public partnership, funded on a year-to-year basis, and is dependent upon the availability of program funds. If funding is available, and if all other program guidelines/criteria are satisfactorily met, CCAP will fund tuition fees needed if financial aid is not available or does not adequately cover tuition. CCAP covers the cost of tuition for up to two years. CCAP DOES NOT cover books, supplies, or room and board expenses.
	5. I understand I must maintain the following cumulative GPA, based on the program for which I am applying: Botetourt County = 2.5 GPA Craig County = 2.5 GPA Franklin County = 2.5 GPA Roanoke City = 2.0 GPA Salem City = 2.5 GPA
	6. I understand if I enroll in the 2013 summer semester, I may take up to 6 credits and must pass these credits with the required cumulative GPA or greater to receive CCAP funds. If I do not pass these credits, I must reimburse the program for the amount issued for the summer semester and I will no longer be eligible to receive CCAP funds for the 2013 fall semester.
	7. I understand CCAP will not pay for developmental courses beyond my first year.
	8. I understand that I must maintain full-time enrollment in a specific program of study - a minimum of 12 credit hours during each semester and not more than 15 credit hours during each semester - pass all coursework, receive the required cumulative GPA, and successfully complete any developmental coursework attempted. If I do not do so in any given semester, I will no longer be eligible for CCAP and must reimburse the program for the amount issued for tuition during that semester.
	9. I understand that if I am taking the maximum 15 credit hours and decide to drop back to 12 credit hours, I must drop the credits by the college's last date to drop for a refund. If I drop back to 12 credit hours after the last date to drop for a refund, I must reimburse the program for the credits dropped by the end of that semester. If I do not reimburse the program by the end of that semester, I will no longer be eligible for CCAP in future semesters.
	10. I understand that I may be asked to attend a recognition ceremony, and that I must attend if scheduled.
	11. I authorize employees of Virginia Western Community College to review my transcript as needed to confirm program eligibility.
	12. I understand that if the information provided on this application is found to be inaccurate, I may be ineligible to participate in CCAP.

Upon submission, you will see a copy of this application to print for your records. Only click "submit application" once.

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Roanoke, VA 24038
540-857-VWCC

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