Penn Highlands Academy Application

Student Information

First Name

Middle Name

Last Name

Note: Please provide an email address that you will use to Receive Your Username.

Email Address

Confirm Email Address

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

Address Information

Street

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 - (Format: mm/dd/yyyy)

Social Security Number - (Format: No hyphens, e.g. 123456789)

Race Information

Race (Choose 1 or more)

Ethnicity

Parent/Guardian Information

Parent/Guardian First/Last Name

Parent/Guardian Street

Parent/Guardian 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

Do you authorize the above listed Parent/Guardian consent to access your academic records?

The Family Educational Rights and Privacy Act (FERPA) of 1974 protects the privacy of educational records.  By selecting YES, I, the student agree to the release of my academic and billing/account information to the Parent/Guardian listed on this application. I understand that I can change this access at any time by contacting the Registrar's Office.

High School Information

What High School do you attend?

When will you Graduate?

Transcripts

Instructions:

Before you are able to submit your application, your will need to upload your high school transcripts.

To upload your transcripts click on the "Choose a File" button and select the PDF file located on your computer or device, then select "Open" to upload your transcript.

Please upload your Transcript: (PDF Format)

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