Camp Community College – Senior Citizens Agreement Form

This form must be filled out and approved before the start of classes. Once approved you will be enrolled on a space-available basis after all tuition-paying students have been accommodated. Only exception to this procedure is when the senior citizen has completed 75% of the requirements for the degree.

* Indicates a required field.

Semester

Fall

Spring

Summer

Personal Information

Last Name

Date

First Name

SSN

Emplid ID

Date of Birth

Address

Home Phone

Address (line 2)

Work Phone

Option 1 — Free Tuition & Fees for Credit Courses

I hereby certify that I am eligible for free tuition and fees for credit courses, part-time, or full-time. I am a legal resident of Virginia and I have a taxable income not exceeding ($23,850) for Federal income tax purpose for the year preceding the year in which enrollment is sought.

Courses
Course Code	Dept.	Course No.	Section	Campus	Day / Time	Credits




Total Credits

Option 2 — Free Tuition for Audit / Non-Credit Courses

I hereby certify that I am eligible for free tuition for Audit of credit courses or for taking non-credit courses (not to exceed three courses per semester). I am 60 years of age or older and I am a legal resident of Virginia.

Courses
Course Code	Dept.	Course No.	Section	Campus	Day / Time	Audit
						X
						X
						X
						X

X = No Grade received

Totals & Signature

Total Credits

Total Tuition ($)

Student Signature :