College Bridge Program Registration - Johnsburg

If you see this don't fill out this input box.

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

Mialing Address*Street Name/Number/Or PO BOX

Home City*Home City

Home State*Home State

Home Zip Code*Home Zip Code

Date of Birth*Do not need a specific time- put anything

Family Telephone Number*Family Telephone Number

Student Email Address*Personal Email Address (not high school email)

County of Residence* Please Select Essex Franklin Hamilton St. Lawrence Lewis Clinton Warren WashingtonCounty of Residence

Citizenship

I am a US Citizen

I am not a US Citizen

I am an international student

Citizenship

Gender

Female

Male

Other/Non-Binary

Gender

Ethnicity (optional) Please Select American Indian/Alaskan Native Native Hawaiian/Pacific Islander Asian White Black/African American Two or More RacesEthnicity (optional)

High School Level

Junior

Senior

High School Level

Home High School*Home High School

Location Courses

ENG 105 EPL - Public Speaking

ENG 222 EPL- Technical Writing

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 22 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 22 2026 I will be removed from the program without notice.

Signature

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