Back-to-Work Initiative Scholarship Application
Email the completed form and student impact statement to swepsonv@durhamtech.edu. The form may be signed
electronically or print out the form, sign it, and scan or photograph it and attach it in the email. The student
impact statement must also be attached in the same email.
Applicant Information
Last Name ________________________________ First Name _______________________ MI _____
Address _____________________________________ City _____________
Phone: Home ___________________ Business ___________________
State _____
Cell __________
Zip _________
_________
Email Address _______________________________________________
Target Group Affiliation (check all that apply)
☐ Unemployed / Underemployed Adult ☐ NC National Guard Member ☐
☐ Underserved Populations: Specific Workforce Sector or Area
Military Veteran or Spouse
Gender Current Employment Status
☐ Female ☐ Male ☐ Unemployed ☐ Underemployed ☐ Employed Full Time
Ethnicity
☐ African American ☐ American/Alaskan Native ☐ Asian ☐ Hawaiian/Pacific Islander
☐ Hispanic/Latino ☐ Non-Hispanic/Latino ☐ White/Caucasian
Student Impact Statement
Please write at least 150 words about how you and y
our family have been affected by COVID-19 and how this
scholarship would impact you. Please print or type your statement on a separate sheet of paper and attach your
final statement to this form. Applications will not be accepted without this statement.
Photography Release/Authorization
☐ Yes ☐ No I hereby consent that all photographs taken of me and stories shared by me may be used by
Durham Technical Community College for the purpose of illustration, advertising, college web information and
promotion, or publication in any manner promoting Back to Work.
Signature ____________________________________________ Date ________________________
Revised 7/14/2020
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signature
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