2017 Summer Application

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1 The North Carolina Community College System GOLDEN LEAF SCHOLARS PROGRAM TWO-YEAR COLLEGES 2017 Summer Application DEADLINE: Friday, June 2, 2017 The Golden Leaf Scholars Program is a need and merit based award of $ awarded to Occupational Education (Continuing Education) students for the SUMMER term. To be eligible, an Occupational Education student must: Be a permanent resident of one of the 79 eligible counties as designated by the Golden LEAF Foundation (See box at left). Be enrolled in a Jobs Now program or a credentialing program of at least 96 hours. Demonstrate a financial need under the federal TRIO formula listed below: Family Unit Federal TRIO Programs Current Year Low-Income Levels 48 Contiguous States $17,820 $24,030 $30,240 $36,450 $42,660 $48,870 $55,095 $61,335 Alamance Granville Person Alexander Greene Pitt Alleghany Halifax Randolph Anson Harnett Richmond Ashe Haywood Robeson Avery Hertford Rockingham Beaufort Hoke Rowan Bertie Hyde Rutherford Bladen Jackson Sampson Burke Johnston Scotland Caldwell Jones Stanly Camden Lee Stokes Caswell Lenoir Surry Catawba Lincoln Swain Cherokee Macon Transylvania Chowan Madison Tyrrell Clay Martin Vance Cleveland McDowell Warren Columbus Mitchell Washington Craven Montgomery Wayne Davidson Nash Wilkes Davie Northampton Wilson Duplin Onslow Yadkin Edgecombe Pamlico Yancey Franklin Pasquotank Gates Pender Graham Perquimans Students who have not completed the FAFSA application ( MUST attach a copy of their 2015 Federal Tax Return, along with the completed application and signed statements and social security waiver form to: WPCC Financial Aid Office 1001 Burkemont Ave Morganton, NC

2 1) Name SID# First Middle Last 2) Mailing Address Street, P. O. Box City State Zip 3) U. S. Citizen? Yes No If not, U.S. permanent resident? Yes No 4) Are you a North Carolina resident? Yes No 5) What is your NC County of permanent residence? Length of residence in county: less than 5 years 5 10 years more than 10 years (To be eligible for this scholarship, your permanent residence must be in an approved NC county.) 6) Address: Telephone 7) Number of People in Your Household: 8) Are you currently receiving other educational financial assistance? Yes No If yes, what type? 9) Education Information: Enrollment Status: Full Time Part Time Program: 10) Completed FAFSA for academic year. Yes No 11) Have members of your immediate family worked for or owned a farming or agricultural related business now or in the past? Yes No 12) Have you or members of your immediate family been employed in traditional industries such as furniture, textiles, or tobacco manufacturing? Yes No 13) Has anyone in your household lost their job in the past two years? Yes No 14) Has anyone in your household transitioned from a full-time job to a part-time job? Yes No 15) Are there other circumstances that demonstrate your need for educational assistance?: 16) List educationally related costs associated with participation in your program/course of choice. 17) Please list all leadership and/or community activities you are currently involved in. 18) Please place an X on the blank beside the intended use of these funds, if awarded. Tuition Fees Books Supplies Mid-Skills Credentialing Exams *Childcare *Transportation *Please Note: Students using funds for Transportation and Childcare purposes will be asked to sign a statement regarding usage.* I have read and understand the requirements for assistance. I hereby declare that the information provided on this form is complete and correct to the best of my knowledge. Applicant s Signature

3 The North Carolina Community College System GOLDEN LEAF SCHOLARS PROGRAM TWO-YEAR COLLEGES USE OF FUNDS STATEMENTS: Use of childcare funds statement: If selected for funding from the Golden LEAF Scholars Program Two-Year Colleges, I certify that scholarship funds designated for childcare will be used exclusively while I am attending class in order to fulfill my educational requirements. Applicant s Signature Use of transportation funds statement: If selected for funding from the Golden LEAF Scholars Program Two-Year Colleges, I certify that scholarship funds designated for transportation will be used exclusively for the purpose of supporting my travel to and from the college where I am enrolled for educational purposes. Applicant s Signature

4 College Media Consent Agreement Golden LEAF Scholars Program 2 year Colleges (This form is for college media release and should be filed at the college. Please do not send this form to the NCCC System Office.) The Federal Family Education Rights and Privacy Act of 1974 (FERPA) prohibits colleges and universities from providing certain information from student records to third parties. FERPA is a Federal law that protects the privacy of student education records. In general, in order for your college or university to release information protected by FERPA to anyone, other than yourself, you must approve the release. I have read and understand the requirements for the Golden LEAF Scholars Program 2 Year Colleges. I understand and agree that if I am selected as a scholarship recipient for the Golden LEAF Scholars Program 2 Year Colleges, the college can share my name and contact information and information regarding my use of Golden LEAF scholarship funds and my program of study with Golden LEAF for its purposes including monitoring, assessment, implementation, and administration of the scholarship program. Applicant s signature Parent or Guardian s Signature (If applicant is under 18) Media Release You must check one of the following options below: I approve the release of my information (name, town, program of study) for a media release announcing my Golden LEAF scholarship I do NOT approve the release of my information (name, town, program of study) for a media release announcing my Golden LEAF scholarship Applicant s signature Parent or Guardian s Signature (If applicant is under 18)

5 Attachment VIII Golden LEAF Scholars Program Two-Year Colleges Social Security Number Waiver Form College: Student Name: The Golden LEAF Foundation requires that every student receiving funds from the Golden LEAF Scholars Program Two-Year Colleges, be tracked for graduation and employment status. This necessitates submission of a student s social security number and address which will be used only for this purpose. The Family Education Rights and Privacy Act (FERPA) and state law (Session Law ) require permission to be given for social security numbers to be used for this purpose. Please check the statement that applies. I hereby give my permission for my social security number, address, and address to be used for tracking purposes only in relation to the Golden LEAF Scholars Program Two-Year Colleges. I do not give permission for my social security number nor addresses to be used for any purpose relating to the Golden LEAF Scholars Program Two-Year Colleges. By checking this option, you will not be eligible for an award. Student Signature Financial Aid Officer

6 Page 2 Waiver Form Golden LEAF Scholars Program Two-Year Colleges Social Security Number Waiver Form Student s Social Security Number: Student Signature

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