Fillable Isothermal Community College Golden LEAF Scholarship Application

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Isothermal Community College Golden LEAF Scholarship Application

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The Isothermal Community College Golden LEAF Scholarship Application form is 2 pages long and contains:

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File type: PDF

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Isothermal Community College
Deadline Friday October 11, 2019
Instructions: Complete this application and return to Isothermal’s Financial Aid Office. This scholarship
is for the current fall 2019 semester only. You will need to reapply for the following semesters.
Personal Information:
Full Name: _________________________________________________________________________
Social Security Number: ___________________________Student ID #: ________________________
Home Address: _____________________________________________________________________
City, State, Zip Code: ________________________________________________________________
E-Mail Address: _____________________________________________________________________
Phone Number: _____________________ Mobile number: ____________________
NC County of 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.)
Educational Information:
Current program of study: _________________________________________
What is your GPA? _____ Is this your 1
st
semester? ____ yes ____ no
Other Information:
Have members of your immediate family worked for or owned a farming or agricultural related business
now or in the past? ____ yes ____ no
Have you or members of your immediate family been employed in traditional industries such as furniture,
textiles, or tobacco manufacturing? ____ yes ____ no
Has anyone in your household lost their job in the past two years? ____ yes ____no
Has anyone in your household transitioned from a full-time job to a part-time job? ____ yes ____ no
Please list all campus and community service activities you are currently involved in.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Use of Funds:
Tuition ____ Fees ____ Books ____ Supplies ____ Mid-Skills Credentialing Exams
____ *Childcare _____ *Transportation
(* Students using funds for childcare and/or transportation purposes are asked to sign the statement(s)
below.)
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 Date
Please complete and return to Isothermal’s Financial Aid Office by October 11, 2019.
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 Date
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 Date
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 Date
______________________________ _______________
Parent or Guardian’s Signature Date
(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 Date
______________________________ _______________
Parent or Guardian’s Signature Date
(If applicant is under 18)
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Isothermal Community College Golden LEAF Scholarship Application

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Completed 19 February 2020

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