Community College Access Program

Application for Future Program Participants

If you have any questions, please contact Carolyn Payne at cpayne@virginiawestern.edu or call 857-6371.

For important details and deadlines, please refer to the CCAP information checklist that pertains to your locality:

All fields are required unless otherwise indicated. Only complete this application if you graduated in June 2013 from a high school in Botetourt County, Craig County, Franklin County, Roanoke City, Roanoke County, or Salem City.

Application is due March 29, 2013.

Future Program Application

Applicant Information

Last Name:

First Name:

Middle Initial: (optional)

Virginia Western Student ID # (Emplid):

To acquire your EMPLID, you must first complete the online application to Virginia Western. You will receive the EMPLID (also called the VWCC student identification number) at the end of that application and then will be able to complete the CCAP application.

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)

Interest Essay

Please answer the following question in the space provided below in 100 - 250 words:

Why do you want to attend Virginia Western Community College, and what do you hope to achieve at Virginia Western?

High School Information

From which high school will you receive your diploma?

What date you will graduate? MM/YYYY

What is your high school student ID number?

Will you complete your full junior and senior year at the high school indicated above? Yes No

Proof of Residency

Note: The documents required in this section must be HAND DELIVERED to the Virginia Western Educational Foundation, 3093 Colonial Avenue, Fishburn Hall (#F214), or an Educational Foundation representative at your high school (dates to be determined) by March 29, 2013.

Where do you currently reside? Botetourt Co. Craig Co. Franklin Co. Roanoke City Roanoke Co. Salem City

How long have you lived in this city/county?

How long have you resided at the address shown on this application?

If you have lived less than 20 months at your current address, please list all your addresses for the period beginning August 2011 in the space provided below, or list each address on a separate sheet of paper, SIGN the paper, and HAND DELIVER it with the documents to the Virginia Western Educational Foundation or an Educational Foundation representative at your high school (dates to be determined) by March 29, 2013.

Additional Addresses:

A custodial parent or court-approved legal guardian MUST SUBMIT proof of residency for a minimum period of 20 months, August 2011 through February 2013 or after. All documentation must include a physical address and a date. Please HAND DELIVER one document from Column A and one from Column B to the Virginia Western Educational Foundation, or an Educational Foundation representative at your high school by March 29, 2013 to fulfill this requirement.

One (1) Document from Column A AND One (1) Document from Column B

Column A
(for period beginning, or before,
August 2011)

2010 Tax Form OR W-2 Form (do not include schedules)
Bill dated on or before August 2011 (cell phone bill, utility bill, insurance bill, cable bill, etc.)
Apartment Lease on or before August 2011
Personal Property Tax Receipt dated on or before August 2011
2011 Mortgage Statement
Child support papers dated on or before August 2011

Column B
(for period ending February 2013 or after)

Current bill dated in February 2013 or after (cell phone bill, utility bill, insurance bill, cable bill, etc.)
Apartment Lease on or through February 2013 or after
Mortgage statement dated February 2013 or after
Current Personal Property Tax Receipt dated February 2013 or after
Letter from utility company stating service is current - must be dated February 2013 or after
Child support papers dated February 2013 or after

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 Botetourt County, Craig County, Franklin County, City of Roanoke, Roanoke County, or City of Salem.
	3. I understand that I must complete and submit the Free Application for Federal Student Aid (FAFSA) and CCAP application annually so that a determination can be made regarding eligibility for financial assistance.
	4. I authorize my current high school to release my midterm GPA to the Virginia Western Educational Foundation to determine my eligibility for the CCAP program. I understand I must have a senior year 2.0-2.5 mid-term GPA (as per district requirement) and graduate from high school with a diploma and a minimum cumulative GPA as follows: Botetourt County = 2.5 GPA Craig County = 2.5 GPA Franklin County = 2.5 GPA Roanoke City = 2.0 GPA Roanoke County = 2.5 GPA Salem City = 2.5 GPA
	5. I understand that I must take the college's placement tests and achieve satisfactory scores by March 29, 2013, and if I need more than 2 developmental courses, I will not be eligible for CCAP.
	6. I understand CCAP, a private/public partnership, is 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.
	7. I understand, once enrolled at Virginia Western, 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 Roanoke County = 2.5 GPA Salem City = 2.5 GPA
	8. I understand CCAP will pay for up to eight (8) credits or 2 classes of developmental courses (if needed) during my first and second semester. These credits must be completed successfully, or I must reimburse the program for that semester.
	9. 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.
	10. 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.
	11. I understand the Virginia Western Educational Foundation strongly recommends that I do not work during the first semester of the program to improve my academic success.
	12. I understand I am required to attend a Virginia Western Discover/CCAP Orientation session.
	13. I understand I must take and pass a College Success Skills Course (1 credit) during my first semester. If I do not pass this course, I must reimburse the program for the amount issued for tuition during the semester, and I will no longer be eligible for CCAP in future semesters.
	14. I understand that I CANNOT take any online/hybrid courses during the first semester.
	15. I understand that I may be asked to attend a recognition ceremony, and that I must attend if scheduled.
	16. I understand CCAP has a community service component that I will be required to complete.
	17. I understand that admission to Virginia Western Community College does not imply or guarantee acceptance into the CCAP program.
	18. I authorize employees of Virginia Western Community College to review my transcript as needed to confirm program eligibility.
	19. I understand that if the information provided on this application is found to be inaccurate, I may be ineligible to participate in CCAP.