College Bridge Program Registration

Student First Name*Student First Name

Student Last Name*Student Last Name

Student Middle Initial*Student Middle Initial

Social Security Number*SSN- Do not enter zeros or you will not be registered

Mailing Address*Street Name/Number/ Or PO BOX

Home City*Home City

Home State*

Home Zip Code*Home Zip Code

Date of Birth*Date of Birth

Family Telephone Number*

Student Email Address*Do not use your school email

County of Residence*

High School Level*

Citizenship*

Gender*

Ethnicity (Optional)

Please check the boxes of the classes you will be taking for college credit this year:

Signature

I understand that by signing this registration form I am formally enrolling in courses offered by North Country Community College at my high school. I have indicated my choice on the form below. I understand that New York State Education Law allows me to enroll in these courses without a signature from my parent or guardian.

I am responsible for paying $75 for each course I select below. I understand that I will receive a green bill at my mailing address which I will have to pay unless I formally drop these courses before October 15 2026. I can inform my instructor and/or guidance counselor prior to that date. If I do not I will still have to pay for the course even if I choose not to participate at a date after October 15 2026.

I further understand that I will need to provide my social security number to facilitate official enrollment receipt of transcripts and reporting processes as established under Section 355 of the Education law of the State of New York. If I do not provide my social security number by October 18 2026, I will be removed from the program without notice.

Signature

College Bridge Program Registration - Brushton