Admission Deposit Form - Complete Online - Washington County Community College

Student Information

Please Provide Your Contact Information Below

Last Name(Required)

First Name(Required)

Middle Initial

Program of Study

Personal Email Address(Required)

Phone Number

Mobile Phone Number

Date of Birth(Required)

Mailing Address

Emergency Contact

Please Provide Emergency Information Below

Who Would You Like Us to Notify In the Event of an Emergency?(Required)

Relationship(Required)

Their Phone Number(Required)

Their Mobile Phone Number

Their Email Address

Their Address(Required)

Health Insurance Information

Please Provide Your Health Insurance Information In the Event of an Emergency

Name of Health Insurance Company

Policy Number

Name of Policy Holder

Local Newspaper

This information is used to publish academic successes of WCCC Students.

Name of Newspaper

Email Address for Your Local Newspaper

Mailing Address for Your Local Newspaper

Payment

You can pay your admission deposit directly online with a debit or credit card using Paypal. This deposit is credited toward your upcoming semester charges and is not an additional fee.

Student Signature

By signing below, you understand that Placement in the program of study is not secured until the admission deposit is received. This deposit is credited toward your upcoming semester charges and is not an additional fee. Should you decide not to attend WCCC, this deposit can be refunded up to 120 days prior to semester start date.

Check This Box and Type Your Name Below to Digitally Sign This Form

Admission Deposit Form – Complete Online

Admission Deposit - WCCC