MIDLANDS YOUTH APPRENTICESHIP APPLICATION CHECKLIST

APPLICATION PACKET MIDLANDS YOUTH APPRENTICESHIP APPLICATION CHECKLIST Please make sure to complete all steps in the application process and submit all required documentation. Incomplete applications will not be sent to hiring companies. The following items are needed for your application to be processed: Midlands Youth Apprenticeship Application Please type, or write legibly in blue or black ink. Lottery Tuition Assistance Waiver Request Form Qualifying Placement Test Scores (see separate admissions and program requirements packet) Cover Letter Cover Letter should include the following items: > Why do you want to be a youth apprentice? > How do your career interests relate to the apprenticeship for which you are applying? > Why do you think you should be hired for a youth apprenticeship? Resume Resume should include the following items: > Education (include any courses/training that support your qualifications and interest in a youth apprenticeship) > Awards and honors > Extracurricular activities > Any employment history > Volunteer work/community service > Interests and skills Two Recommendation Forms: > Within a school setting (teacher, coach, school counselor) > An individual in the community (volunteer coordinator, youth director, employer, etc.) > A relative is only acceptable if he or she has supervised you in a paid work setting. FERPA Release of Information Form Media Consent and Release Form Submit completed packet to your high school s work-based learning coordinator. Page 1 of 9

APPLICATION APPLICATION Please print or type: Last Name First Name Middle Social Security # Local Address (include apt. #) City State Zip Code Permanent Address (include apt. #) City State Zip Code Phone Number(s) Student Email Address Parent/Guardian Email Address 1. ADMISSION STATUS Please check one of the following options and answer any related questions. o New Student: I have never attended college. Current High School: Current High School Grade Level: o Former MTC Student: I have taken course(s) at MTC before. If so, the last date I attended was: I was suspended from MTC: o No o Yes 2. BIRTHDATE (mm/dd/yyyy) / / 3. SEX o Female o Male 4. ETHNICITY o Hispanic Latino o Non Hispanic / Non-Latino 5. RACE o Asian o Black / African American o White 6. ENROLLMENT PLAN Semester: 7. CITIZENSHIP STATUS o American Indian / Alaskan Native Year: 8. RESIDENCY INFORMATION I have (or the person who claims me as a tax dependent has) lived in the state of South Carolina continuously for the last 12 months. o Yes o No (See South Carolina residency guidelines at http://www.che.sc.gov) If no, I resided in the following state(s): I have (or the person who claims me as a tax dependent has) lived in Richland, Lexington, or Fairfield county continuously for the last 12 months. o Yes My county of legal residence is: o No 9. PROGRAM PREFERENCE Please choose one of the following (admissions and program requirements can be found in the Midlands Youth Apprenticeship Admissions and Program Requirements packet): o CNA/Nursing Pathway o Pharmacy Technician 10. EMERGENCY CONTACT Name / Relationship I am a United States citizen: o Yes If no, what country? If no, my status in the United States is: o No Phone Number o Permanent Resident o Visa (Specify) o Other o Refugee / Asylee / Parolee If you are not a U.S. citizen, please submit a copy of your U.S. Citizenship and Immigration Services documentation with this application or within two weeks by email to international@midlandstech. edu; in person; or by mail to Midlands Technical College, Admissions Office, ATTN: International Coordinator, PO Box 2408, Columbia, SC 29202. Midlands Technical College does not discriminate in admissions, educational programs or employment on the basis of race, sex, sexual orientation, national origin or ethnic group, color, age, religion, disability, genetic information, gender, military service, pregnancy or other category protected by applicable law. In compliance with all federal and state laws, including the Age Discrimination Act of 1967, Title VI and Title VII of the Civil Rights Act of 1964 and Title IX of the Education Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1992 as well as the ADA Amendments of 2008 (ADAA), and the Genetic Information Nondiscrimination Act of 2008 (GINA), Midlands Technical College offers access and equal opportunity in its admissions policies, academic programs and services, and employment of disabled individuals in that no otherwise qualified person will be denied these provisions on the basis of a disability. Midlands Technical College also prohibits retaliation against any person for bringing a complaint of discrimination or for participating in an investigation of a complaint of discrimination. Mr. Ian A. MacLean has been designated to coordinate compliance with the nondiscrimination requirements contained in Section 35.107 of the Department of Justice regulations, Sections 503 and 504 of the Rehabilitation Act of 1973, Title VI and Title VII and Title IX regulations. Information concerning the provisions of the Americans with Disabilities Act and the rights and privileges thereunder are available from Mr. Ian A. MacLean in his position as Director of Internal Audit and Risk Management and the Chief Compliance Officer for Affirmative Action, Equal Opportunity, Sexual Harassment, Disability Action and the Title IX Coordinator. He can be reached at Midlands Technical College, PO Box 2408, Columbia, SC 29202, 803.822.3204, macleani@midlandstech.edu. Page 2 of 9

AGREEMENT FORM STUDENT AGREEMENT To be successful, I must attend class and maintain communication with instructors and the high school counselor. I understand that the amount of work necessary to succeed in these courses may be much greater than in high school courses. In addition, Midlands Youth Apprenticeship courses become a part of my permanent college transcript. It is important to do well in these courses to realize all the benefits of the program. Midlands Youth Apprenticeship students are treated the same as any other college student and are subject to all college policies governing students while attending classes offered by Midlands Technical College (MTC). I understand that by becoming a Midlands Youth Apprenticeship student, I must abide by the high school s, the college s, and the employer s rules and regulations. As a dependent of my parent, I give MTC permission to release any information regarding my grades, attendance, academic standing, disciplinary action, financial obligations, or any other aspect of my student life to my parents or legal guardians. I also understand that grades, attendance, and any other academic information will be provided to the high school and employer as part of this agreement. I certify that the answers on this application are true, correct, and complete. I further certify that I will notify the MTC Admissions Office immediately if I change my state of legal residence or if my residency status otherwise changes. I attest that I am a U.S. citizen, a legal permanent resident in the United States, or an alien lawfully present in the U.S. I will submit documentation to support this claim upon request. The South Carolina Illegal Immigration Reform Act (SC Code Ann. 59-101-430 (Westlaw 2008)) prohibits those unlawfully present in the United States from attending a public institution of higher education in South Carolina and from receiving a public higher education benefit. I understand that submitting false or incorrect information may make me subject to dismissal from the college. Any student who is found to be unlawfully present in the U.S. will be dismissed from the college. In the event that I incur a debt as a result of my attendance at the college, I understand any costs associated with collections will be charged to me as the debtor. Student Signature PARENT PERMISSION AGREEMENT I understand that by allowing my child to participate in the Midlands Youth Apprenticeship program, I will be responsible for following the guidelines and academic calendar of not only the high school, but also of the college and employer. I hereby give my permission for my son/daughter, in the Midlands Youth Apprenticeship program at Midlands Technical College., to participate Parent or Legal Guardian Signature HIGH SCHOOL AGREEMENT TO BE FILLED OUT BY HIGH SCHOOL Grade Level (during enrolled term): o Sophomore o Junior o Senior Anticipated Graduation Year: Principal or Designee (printed): Signature and : High School Comments: Page 3 of 9

VERIFICATION OF LAWFUL PRESENCE FORM Please type, or use blue or black ink; do not use pencil. Student s Name Social Security # Career Center / High School Program / Major Received All students must be prepared to provide at least ONE of the following documentation types or combinations as evidence of U.S. legal presence. > Valid S.C. Driver s License > Valid Learner s Permit > Valid S.C. State ID > Valid U.S. Passport > Valid Permanent Residency Card > Valid Federally Issued Visa and a Current School-Issued ID (verified through SAVE) > Valid Birth Certificate accompanied by a Current School-Issued Picture ID Copy Documentation Below: Student Signature Parent/Guardian Signature Page 4 of 9

2018-2019 LOTTERY TUITION ASSISTANCE WAIVER REQUEST Last Name First Name MI MTC ID Address City State Zip Code Phone Number I request a waiver to the Lottery Tuition Assistance eligibility requirement relating to the submission of the Free Application for Federal Student Aid (FAFSA) for the following reasons (check all that apply): o I am a high school student enrolled in a dual enrollment program. o I have already earned a Bachelor s Degree and have provided an official transcript to the MTC Admissions Office. o I am enrolled in a program that is not eligible for Title IV federal aid. o I am a dependent student who cannot get my parents signature or Tax Return Transcript. (You must attach a letter from your parents confirming this statement) o I am an independent student who cannot get my spouse s Tax Return Transcript. o I am an independent student and my adjusted gross income is at least $80,000. I will provide a copy of my Federal Tax Return Transcript. o I am a dependent student and my parent s adjusted gross income is at least $80,000. I will provide a copy of their Federal Tax Return Transcript. BY NOT SUBMITTING THE FAFSA, I ACKNOWLEDGE THAT: I will not be eligible to receive other Title IV aid, which includes the Pell Grant, Federal Supplemental Educational Opportunity Grant, Perkins Loan, Stafford Loans, Federal Work Study, and the S.C. Need-Based Grant. Also, I will not be able to participate in state assistance programs that require the submission of the FAFSA. Further, I understand that neither the state of South Carolina nor the institution can be held liable for any amount of federal or state funds that I forgo by signing this waiver. I do not owe a refund or repayment of a state grant, Pell Grant, or Supplemental Educational Opportunity Grant, and I am not in default on a loan under the Federal Perkins Loan, Federal Stafford Loan, William D. Ford Federal Loan, or any state loans. I understand that the institution will verify this. Male Students Only: I have registered with the Selective Service, or I have been exempted from this requirement according to federal law. I understand that students who fail to register with the Selective Service or fail to be exempt from that requirement are not eligible to receive Lottery Tuition Assistance. The provided information is correct, and if any of the information is false, I understand participation in the Lottery Tuition Assistance Program will be canceled and reimbursement of Lottery Tuition Assistance funds will be required. Further, I understand that if I have attempted to obtain or have obtained Lottery Tuition Assistance through means of a willfully false statement or failure to reveal any material fact, condition, or circumstance affecting eligibility, I can be subject to the college/university s code of student conduct and applicable civil or criminal penalties. This waiver is not valid until all requested documentation is provided to the financial aid office, and all documentation has been verified. Student Signature Financial Aid Signature Office Use Only o Approved o Not Approved Page 5 of 9

FERPA RELEASE OF INFORMATION FORM Students enrolled in Midlands Technical College courses are protected by the Family Educational Rights and Privacy Act (FERPA) of 1974. Federal law prohibits institutions from disclosing and/or discussing any information about a student without written, signed release. I,, (Print Full Name of Student) hereby authorize Midlands Technical College to release information relative to my initial Midlands Youth Apprenticeship application, including college records, to my high school and potential employers engaged in the Midlands Youth Apprenticeship program. Initial information to be released: o Youth Apprenticeship Application Form o Cover Letter and Resume o Recommendation Forms o Placement Test Scores Information to be released upon employment in the Midlands Youth Apprenticeship program and admission to the college: o Academic Information (Transcripts) o Enrollment o Financial Aid o Other: Student Name Student Signature Student of Birth High School Page 6 of 9

MEDIA CONSENT AND RELEASE FORM 1. I,, parent/guardian of (Print Name of Parent or Guardian) (Print Name of Student), at, (Print Name of High School) hereby grant Midlands Technical College and its agents and others working for the college or on its behalf and its respective licensees, successors, and assigns the absolute right and permission to use, publish, and broadcast my son s/daughter s voice recording, name, picture, and likeness or any material based upon or derived therefrom, or to refrain from so doing, in any manner or media whatsoever for purposes of advertising illustration or promoting and publicizing Midlands Technical College programs. 2. I shall have no right of approval, no claim to additional compensation and no claim including, without limitation, claims based upon invasion of privacy, defamation or right of publicity arising out of any use. 3. I agree that this release does not in any way conflict with any existing commitment on my part. Parent/Guardian Signature Witness Print Name Page 7 of 9

RECOMMENDATION FORM Student Name High School This student has indicated an interest in the Midlands Youth Apprenticeship. To assist us in evaluating this student s potential, please rate his/her performance in each area below (mark one for each). Quality of Work Responsibility Effort Attitude Honesty Teamwork Work Habits Problem Solving Skills No Basis for Judgement Below Average Average Above Average Excellent Below, please provide us with any additional explanation or examples to support your ratings above. Please attach a separate sheet if necessary: Name Relation to Applicant Title/Business/School Signature Page 8 of 9

RECOMMENDATION FORM Student Name High School This student has indicated an interest in the Midlands Youth Apprenticeship. To assist us in evaluating this student s potential, please rate his/her performance in each area below (mark one for each). Quality of Work Responsibility Effort Attitude Honesty Teamwork Work Habits Problem Solving Skills No Basis for Judgement Below Average Average Above Average Excellent Below, please provide us with any additional explanation or examples to support your ratings above. Please attach a separate sheet if necessary: Name Relation to Applicant Title/Business/School Signature Page 9 of 9