Columbus Technical College XLR8 Programs Interest Questionnaire

Please let us know which high school programs interest you. If you provide contact information (a valid email address, phone number or mailing address) we will respond to your questionnaire.

Questions marked with an asterisk (*) must be filled in to submit the questionnaire.

Student Name

Primary Contact Information

Primary Contact Information Home Address:
Home/Primary Contact Telephone Number:

Additional Contact Information

Additional Contact Information Cell/Work/Other Telephone Number:
Email Address:

Name of High School:

Current Year in High School:

Current Year in High School: Freshman

Sophomore

Junior

Senior

Other (please specify)

Date of Birth

	MM		DD		YYYY
Date of Birth:	Date of Birth Date of Birth: Month	/	Day	/	Year

Parent/Guardian Name:

I am interested in the following Dual Enrollment Programs (please check all that apply)

I am interested in the following Dual Enrollment Programs (please check all that apply) Patient Care Assisting (PCA)

Health Insurance Professional (HIP)

Financial Services Professional (FSP)

Certified Manufacturing Specialist (CMS)

Other (please specify program or 'Undecided')

I am interested in Joint Enrollment (please enter programs of interest or enter 'Undecided')

I am interested in Joint Enrollment (please enter programs of interest or enter 'Undecided') Program of Study Choice 1:
Program of Study Choice 2:
Program of Study Choice 3:

I am interested in the ACCEL Program (please list top 3 postsecondary institution choices or enter 'Undecided')

I am interested in the ACCEL Program (please list top 3 postsecondary institution choices or enter 'Undecided') First Postsecondary Institution Choice:
Second Postsecondary Institution Choice:
Third Postsecondary Institution Choice: