myPEAK

General Information

First Name

Middle Name

Last Name

Email Address

Confirm Email Address

Address Information

Street

P.O. Box

City

State

Zip Code

County

Country

How long have you lived at this address?

If less than one year, enter prior county and state of residence:

Primary Phone Number

Cellular Phone Number

Work 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

Citizenship Information

Country of Citizenship

Citizenship Status

Race Information

Ethnicity

Race (Choose 1 or more)

Educational Goals

1. Which Location do you plan to attend?

2. I plan to attend

3. I plan to enroll in the following term

4. I plan to enroll in the following year

High School Information

Name of High School

City

State

Zip Code

Year of High School Graduation

Emergency Contact Information

Name of Person to Contact in Case of an Emergency

Contact Phone Number

Completion

How Did you Hear about Pennsylvania Highlands?

How Did you Hear about Pennsylvania Highlands?

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.

I wish to receive text messages from Pennsylvania Highlands Community College.

Sign and Submit

By entering my name, I acknowledge that I have made application to Pennsylvania Highlands Community College and certify that the information provided on the application is true to the best of my knowledge.

Signature

Date