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Application
Thank you for your interest in the ACT 101 program at Westmoreland County Community College! Please complete this application as thoroughly as possible. If you have any questions, please email us at act101@my.westmoreland.edu
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Email
*
Record my email address with my response
Student ID #
*
Your answer
Last Name
*
Your answer
First Name
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Age:
*
Your answer
Gender Identity
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Female
Male
Agender
Genderqueer
Non Binary
A gender identity not listed here
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Address
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Your answer
Are you a resident of Pennsylvania?
*
Yes
No
Required
Phone
*
Your answer
Westmoreland email
*
Your answer
I authorize the staff of ACT 101 to obtain information from my instructors, Admissions, Records, and Financial Aid Offices pertinent to my participation in the program. If accepted to fully participate.
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Required
Mother's educational level
*
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Bachelor's degree or Higher
Associates Degree
Certificate
High school Diploma
GED
Unknown
Father's educational level
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Choose
Bachelor's degree or Higher
Associates Degree
Certificate
High school Diploma
GED
Unknown
Did you graduate from high school?
*
Yes
No
Received GED
Required
If yes, year of graduation
*
Your answer
Have you been out of school for 3 or more years?
*
Yes
No
Required
Did you complete your FAFSA?
*
Yes
No
Required
How many people are in your household including you?
*
Your answer
Did you complete your math placement test?
*
Yes
No
Required
Check any developmental classes you are currently enrolled in:
*
MTH 050
MTH 052
ENG 085
O95
O99
None
Required
Ethnic Group/Race:
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American Indian or Alaska Native
Asain
Black or African-American
Hispanic or Latino
White
Native Hawaiian or other Pacific Islander
More then one race (check all that apply)
Unknown/No response
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Do you have a disability, if so, please indicate any that may apply:
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Attention Deficit Disorder
Learning Disability
Psychiatric
Sight
Hearing
Disease Related
Mobility Impaired
Other
No disability
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