myPEAK

Dual Enrollment Accelerated College Education (ACE) Application

Student Information

First Name

Middle Name

Last Name

Email Address

Confirm Email Address

(Essential enrollment and payment information will be sent to the email address provided on this form)

Address Information

Street Address (Example 123 Main St.)

Apt. #/P.O. Box

City

State

Zip Code

County

Primary Phone Number

Cellular Phone Number

Demographic Information - ( Optional )

The completion of the following information is voluntary and optional. It will be used to comply with Federal reporting and has no effect on admission to the College. Pennsylvania Highlands Community College is committed to the principle of equal education for all students without regard to race, national origin, marital status, creed, gender, age, or handicap.

Gender

Birth Date

Social Security Number

Race Information

Race (Choose 1 or more)

Ethnicity

Parent/Guardian Information

Parent/Guardian First/Last Name

Parent/Guardian Street

Parent/Guardian Apt. # / P.O. Box

Parent/Guardian City

Parent/Guardian State

Parent/Guardian Zip Code

Parent/Guardian Primary Phone Number

Parent/Guardian Secondary Phone Number

Parent/Guardian Email Address

High School Information

What High School do you attend?

What year will you graduate?

Completion

Electronic Communication

The College may communicate with you in a variety of ways including email and text messaging. Please indicate below if you would like to opt out of receiving text and/or email messages from Pennsylvania Highlands Community College.

I wish to receive emails from Pennsylvania Highlands Community College.

Sign and Submit

By entering my first and last name, I certify that all information reported on this form is complete and accurate to the best of my knowledge.

Student Signature

Date