Fillable SUBMIT APPLICATION BY MONDAY, JUNE 1, 2020 (Martin Community College)

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SUBMIT APPLICATION BY MONDAY, JUNE 1, 2020 (Martin Community College)

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SUBMIT APPLICATION BY MONDAY, JUNE 1, 2020
North Carolina Community Colleges
Golden LEAF Scholars Program – Two-Year Colleges
Student Application
Instructions: Complete this application and return the completed application to the college’s Financial
Aid Office. Occupational Education students must also submit a copy of their transcript with the
application.
Personal Information:
Full Name: _________________________________________________________________________
Social Security Number: _______________________________________________________________
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:
College you are attending: _____________________________________________________________
____ Occupational Continuing Education Student (must be enrolled in a credentialing program of at least
96 hours.)
Program you are enrolled in: _____________________________________________________
____ Curriculum Student: _____ GPA _____1
st
semester _____ not enrolled
Program you are enrolled in: _____________________________________________________
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 return the completed application to the college’s Financial Aid Office.
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
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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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SUBMIT APPLICATION BY MONDAY, JUNE 1, 2020 (Martin Community College)

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Completed 26 July 2020

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