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CCHS Academy Interest Form 2020-21

First Name*

Last Name*

Preferred First Name

Email Address*

Mobile Phone*

Participant Date of Birth*

1

Organization Name (full or partial)

Country

State/Province

City (full or partial)

High School Not Listed or is outside the United States

Actual or Expected Month of High School Completion*

Actual or Expected Year of High School Completion*

High School GPA

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Have you completed High School

YesNo

Transcript GPA

Completed HS Yes Options

Completed HS No Options

Parent Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email Address

Parent/Guardian 1 Phone Number*

Which course format would you consider enrolling in?

Onsite at my high school

Online or Main Campus

Regional Center/ Career Academy

Regional/County Center

Regional/County Center Selection

Career Interest Area

Academic Program Event

Entry Term Event

High School Grad Year Event

Entry Term*

Academic Program*

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It is the policy of Kirkwood Community College not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity,
creed, religion, and actual or potential family, parental or marital status. If you have questions or complaints related to compliance with this policy, please contact the Vice President, Human Resources and
Institutional Effectiveness, 6301 Kirkwood Blvd. SW, Cedar Rapids, IA 52404, 319-398-5572, equity@kirkwood.edu, or the Director of the Office for Civil Rights U.S. Department of Education, John C. Kluczynski
Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560 Facsimile: (312) 730-1576, TDD 800-877-8339 Email: OCR.Chicago@ed.gov.

Notice of Non-discrimination on the Basis of Sex
Kirkwood Community College does not discriminate on the basis of sex (including pregnancy) and prohibits sex discrimination in any education program or activity that it operates, as
required by Title IX and its regulations, including in admission and employment. Inquiries about Title IX may be referred to the College’s Title IX Coordinator, the U.S. Department of
Education’s Office for Civil Rights, or both. The College’s Title IX Coordinator is Melissa Payne, Vice President of Student Services, 3036 Iowa Hall, Melissa.payne@kirkwood.edu, 319-398-
5584. The College maintains grievance procedures for complaints of discrimination and harassment based on sex. The College’s nondiscrimination policy and grievance procedures can be
located at https://www.kirkwood.edu/_files/pdf/about-us/trustees/102_board_policy_non_discrimination_access.pdf. To report information about conduct that may constitute sex
discrimination or make a complaint of sex discrimination under Title IX, please refer to https://www.kirkwood.edu/explore/services/dean-of-students/violence-prevention or contact the
College’s Title IX Coordinator.

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