Student Application Form

Welcome!  As a student in the Worcester Public Schools, you are invited to take advantage of several advanced learning opportunities. Please complete the following application and make sure to mark if you are going to participate in 100 Males to College or the Early College Program.

If you have questions, please contact:

School Guidance Counselor 

Andy Kupec | (508) 854-7418 | akupec@qcc.mass.edu

Michelle Sheehan | (508) 854-2713 | msheehan@qcc.mass.edu

Eriberto “Eddy” | (508) 929-8380 | emoracarrera@worcester.edu


Please complete the Student Application form below

PROGRAM(S) ARE YOU APPLYING FOR *
Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Gender
Ethnicity *
Desired Start *
Current Grade *
Have you taken the QMAT? *
Have you taken the Accuplacer ? *
Parent/Guardian 1 Name *
Parent/Guardian 1 Name
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Home Phone
Parent/Guardian 1 Home Phone
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Home Phone
Parent/Guardian 2 Home Phone
Please share any comments that you feel will help us serve you and your family better. (allergies, concerns, etc.)
Type student’s full name here to electronically sign and certify that all of the information provided on this form is true and accurate. By electronically signing this form, you, the student, certify that you understand that any misrepresentation, omission, or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal. Student Electronically Sign Here