High School Early College Application

General Information

First Name

Middle Name

Last Name

Note: Please provide an email address that you will use to Receive Your Username, Activate Your Account, Change/Reset Your Password, and to use for Multi-Factor Authentication (MFA) on your college account.

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

Note: Please provide a mobile number that you will use to Activate Your Account, Change/Reset Your Password, and to use for Multi-Factor Authentication (MFA) on your college account.

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

Letter of Recommendation

Instructions:

In addition to completing this Application, prospective students must also submit a recommendation from their high school principal or guidance counselor authorizing you to enroll into a college level course.

You can upload your recommendation letter to your application at this time, or you may submit your application and forward it by email to: admissions@pennhighlands.edu

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

Please upload your Letter of Recommendation: (PDF Format)

Emergency Contact Information

Name of Person to Contact in Case of an Emergency

Contact Phone Number

Completion

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.

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