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Please mail completed application to:

Central Washington University

Running Start Program

400 East University Way

Ellensburg WA 98926-7433

CWU ID

__________________________________________________________________________________________________________________________________________________________________________________________

PERSONAL INFORMATION Male  Female

Circle: What year are you in high school now? Sophomore Junior Senior Circle: Term applying for: Fall Winter Spring

Have you earned college credit through CWU or any other institution? No Yes- Please list____________________________________

Public high school you will be enrolled in during Running Start: __________________________________________________________

Last Name ____________________________ First Name_______________________ Middle Name______________________________

Social Security Number ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Mailing Address _________________________________________________________________________________________________

Number and Street / PO Box Apt.# City State Zip Code

Telephone (_____) ___________________________________ Student Cellular Telephone (_____) _________________________

Student Email * _____________________________________ * upon admission students must create an CWU email account

Date of Birth _______________________________________ Birth place _____________________________________________

Month Day Year City State Country (if other than U.S.)

___________________________________________________________________________________________________________________________________________

ETHNICITY (OPTIONAL) (Required for State and Federal Statistics and requested on a voluntary basis. Answers will remain confidential)

White Black/African America American Indian or Alaska Native -Name of enrolled or principal tribe ___________________________________

Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Pacific Islander

No, not Spanish/Hispanic/Latino Yes, Mexican or Mexican American (Chicano) Yes, Puerto Rican Yes, Cuban Yes, other Spanish/Hispanic/Latino

__________________________________________________________________________________________________________________________________________

FAMILY INFORMATION

INFORMATION FROM EDUCATIONAL RECORDS (DISCLOSURE AND CONSENT)

The Federal Educational Privacy Act (FERPA) restricts disclosure of educational records

I consent to the disclosure of my educational records by Central Washington University, which contains information pertaining to my enrollment in University courses and my academic progress in those courses as provided in this consent.

Information may be disclosed to my parents or guardians and appropriate high school and high school district officials for the following purposes:

• To inform them of the potential costs associated with enrollment in University courses when they may be financially responsible.

• To inform them of my progress towards high school graduation (Information could include: grades, student account information, fees, payments, and academic record information etc.)

Student Signature_______________________________________________________________________Date____________________

This release will be on file the entire length of time you are a CWU Running Start student. Please notify our office in writing if any names listed on the front page are no longer eligible to receive information outlined above.

RUNNING START FUNDING LIMITS

The student is responsible (not the high school or college) for maintaining

a schedule that stays within the Running Start funding limits or the student

agrees to pay all university costs incurred for exceeding the funding limit.

If the student enrolls for more university credits than allowed according

the Running Start Funding Limit Table, the student is responsible for:

• Paying all university costs associated with exceeding the limit

• Withdrawing from the excess university or high school course(s)

We (Student and Parent) acknowledge, with our signatures below, that we have read, understand and will comply with the conditions of Running Start participation and the expectations of university course enrollment.

|Student |Parent |

| | |

| | |

|Date___________________ |Date___________________ |

| | |

|Student Signature_________________ |Parent Signature__________________ |

| | |

|Student Printed Name________________ |Parent Printed Name_________________ |

| | |

Disability Accommodations & Disclosure: Postsecondary education institutions may set their own requirements for disabilities documentation so long as they are reasonable and comply with Section 504 and Title II.  It is not uncommon for documentation standards to vary from institution to institution. A student must provide documentation, upon request, that he or she has a disability, that is, an impairment that substantially limits a major life activity and that supports the need for an academic adjustment.  Institutions of postsecondary education are not required to conduct or pay for an evaluation to document a student’s disability and need for an academic adjustment.  An IEP or Section 504 plan is generally not sufficient documentation to support the existence of a current disability and need for an academic adjustment from an institution of postsecondary education. 

CWU provides equal opportunity in education without regard to race, color, creed, religion, national origin, sex, age, marital status, disability or status as disabled veteran or Vietnam-era veterans in accordance with institutional policies and applicable federal and state statutes and regulations

-----------------------

CWU ID:

(optional)

Mother or legal guardian

Name ______________________________________________________

Last First

Telephone (_____) ____________________________

Work Phone (_____) _______________Cell (_____) ________________

Address ____________________________________________________

Number and Street

______________________________________________________________________________

City State Zip Code

Email ______________________________________________________

If parent, has she received a Bachelors or higher? [pic] Yes [pic] No

Has she attended Central Washington University? [pic] Yes [pic] No

Father or legal guardian

Name ________________________________________________

Last First

Telephone (_____) ______________________________________

Work Phone (_____) ______________Cell (_____) ____________

Address _______________________________________________

Number and Street

______________________________________________________________________

City [pic]

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Email ________________________________________________

If parent, has he received a Bachelors or higher? [pic] Yes [pic] No

Has he attended Central Washington University? [pic] Yes [pic] No

______________________________________________________________________________________________________________________________________________________________________________________

APPLICATION REQUIREMENTS

1. Copy of High School transcript & Copy of College transcript if applicable

2. SAT, ACT or ACT Residual test scores

3. Signature of Public High School Counselor verifying student grade level as indicated in the Personal Information above.

Date___________________ Public High School Counselor Signature______________________

Counselor Printed Name___________________

[pic]

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