Elevate Enrollment Form

Applicant Information

• 
  First Name*
  
  

• 
  Middle Name
  
  

• 
  Last Name*
  
  

• 
  Date of Birth*
  
  

• 
  Student ID Number*
  
  

• 
  Street Address*
  
  

• 
  City*
  
  

• 
  State / Province / Region*
  
  

• 
  ZIP Code*
  
  

• 
  Country*
  
  

• 
  Preferred Language*
  
  

• 
  Email*
  
  

• 
  Cell Phone*
  
  

• 
  Alternate Phone
  
  

• May we text you?*
  YesNo

• Communication assistance required?*
  YesNo

Emergency Contact Information

• 
  First Name*
  
  

• 
  Last Name*
  
  

• 
  Relationship*
  
  

• 
  Contact Phone*
  
  

Application Questions

• At which CCBC campus would you like to receive services?*
  —Please choose an option—CatonsvilleDundalkEssex

• Are you graduating or transferring this semester?*
  YesNo

• Are you receiving the Federal Pell Grant?*
  We will need to verify this information visually.
  YesNo

• Are you taking at least six credits this semester?*
  YesNo

• Is your cumulative GPA at least 2.0?*
  YesNo

• 
  How many total credits have you accumulated at the time of this application?*
  
  

Demographic Information

• Gender*
  FemaleMaleOther

• Marital Status*
  Single (never married)Married/Domestic partnershipWidowedDivorcedSeparated

• Race / Ethnicity*
  Black/African AmericanWhite/CaucasianAsian (not Pacific Islander)Hispanic/Latino(a)Native American/Native AlaskanHawaiian Native/Pacific IslanderOther

• Employment Status*
  Full-timePart-timeTemporary Full-timeTemporary Part-timeUnemployedStudent

• Military Veteran / Actively Serving?*
  YesNo

• Do you have children of your own, ages 0-17, residing in your household?*
  YesNo

• If you answered yes to the last question, please fill out the following questions.

  • 
    Number of biological children in your household
    
    

  • 
    Number of adopted children in your household
    
    

  • 
    Number of foster/temporary custody children in your household
    
    

• Do you have children of your own, ages 0-17, residing outside of your household?*
  YesNo

• If you answered yes to the last question, please fill out the following questions.

  • 
    Number of biological children living outside of your household
    
    

  • 
    Number of adopted children living outside of your household
    
    

  • 
    Number of foster/temporary custody children living outside of your household
    
    

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