Tuition Assistance Application Form

 

TUITION   A SSISTANCE   A PPLICATION   F ORM  

To   b e   c onsidered,   t he   e ntire   a pplication   m ust   b e   c ompleted.  

 

Student’s   N ame  

Date   o f   B irth________________

_ _______________________________________

 

_ _____________________________________________________________________  

Address  

City   _ _________________________________________   S tate   _ _____   Z ip   _ ________________  

Home   P hone   _ ________________Cell   P hone   _ _______________Male/Female   _ ___________  

Email   A ddress   _ ________________________________________________________________  

Ethnicity:   ( for   r ecord-­‐keeping   p urposes)   _ __   W hite   _ __   A frican-­‐American   _ __   A sian-­‐American  

___   H ispanic-­‐Latino   _ ___Native   A merican   _ ___Other  

Parent/Guardian___________________                       P arent/Guardian_________________________    

Employer_________________________                       E mployer_______________________________  

Address__________________________                         A ddress________________________________  

Business   P hone____________________                       B usiness   P hone__________________________  

Email   A ddress_____________________                         E mail   A ddress___________________________  

 

Please   l ist   c lasses   i n   o rder   o f   p reference.   C lasses   a re   s ubject   t o   a vailability.      

Class   T itle                                                                                                       C lass   C ode(s)                       T ime                             T uition  

_____________________________             _ __________  

_______                   _ _________  

_____________________________             _ __________                     _ ______                   _ _________  

_____________________________             _ __________                     _ ______                   _ _________  

 

PLEASE   I NCLUDE   A   C OPY   O F   T HE   T OP   P AGE   O F   Y OUR   M OST   R ECENT   T AX   R ETURN   F OR   P ROOF   O F   I NCOME.  

(A) Annual   R eported   I ncome   $ ______________  

(B) All   o ther   S ources   o f   I ncome   $ _______________  

(Social   S ecurity,   W elfare,   A FDC   c hild   s upport,   a limony,   t ips,   c ash)  

Total   I ncome   ( A+B):   $ _________  

Number   l iving   i n   h ousehold:   A dults__________School   a ge   c hildren____________  

Are   t here   a ny   f inancial   c ircumstances   t o   b e   c onsidered?     I f,   y es   p lease   e xplain_________________________  

________________________________________________________________________________________  

________________________________________________________________________________________  

Have   y ou   r eceived   t uition   a ssistance   i n   t he   p ast?     _ ____Yes_____No  

 

I   a gree   t hat   I   h ave   r ead   a nd   r eceive   a   c opy   o f   t he   T uition   A ssistance   c onditions   a ttached   t o   t his   f orm.     T o   t he  

best   o f   m y   k nowledge   t he   a bove   i nformation   i s   c orrect.  

Parent   ( Guardian)   S ignature_________________________________   D ate___________    

 

[Office   u se   o nly]  

Awarded:  

__________Full   _ _________Partial       $ _________Amount__________   D eclined