Fillable Student Application North Carolina Community Colleges and Golden (Coastal Carolina Community College)

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Student Application North Carolina Community Colleges and Golden (Coastal Carolina Community College)

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The Student Application North Carolina Community Colleges and Golden (Coastal Carolina Community College) form is 4 pages long and contains:

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  • 7 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Coastal Carolina Community College

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Golden LEAF COVID-19 Scholarship Fund
Student Application
North Carolina Community Colleges and Golden LEAF want to aid students directly or indirectly impacted
by the Coronavirus Outbreak and the move to on-line instruction in the Spring 2020 term. Please
complete the application to request assistance with expenses related to COVID-19 (i.e., childcare, living
expenses, internet access, computer). Eligible students must reside in a rural county that is tobacco
dependent, or economically distressed, as determined by the Golden LEAF Foundation. Please see your
school’s financial aid office for a list of 2019-2020 Qualifying Counties.
Instructions: Complete this application and return the completed application to the college’s Financial
Aid Office.
Section One: Personal Information:
F
ull Name: _________________________________________________________________________
S
ocial Security Number/Student ID Number:_______________________________________________
H
ome Address: ______________________________________________________________________
C
ity, State, Zip Code: __________________________________________________________________
E-Ma
il Address: ______________________________________________________________________
P
hone/Mobile Number: ____________________ County of residence: _________________________
Length of residence in county: ____ less than 5 years ____ 5 – 10 years ____ more than 10 years
Section Two: Educational Information:
____
Occupational Continuing Education Student (must be enrolled in a credentialing program of at least
96 hours.)
Program of Study: _____________________________________________________
____ Curriculum Student:
Program you are enrolled in: _____________________________________________________
Section Three: Reason for Applying:
Please indicate the reason you are applying for Golden LEAF COVID-19 Scholarship Fund.
Please desc
ribe how the Coronavirus has affected you and led to your need for assistance from the
Golden LEAF COVID-19 Scholarship Fund:
_____ Student need to purchase laptop, headset for computer or other supplies to assist you in logging in
to complete your courses.
_____ Student short term or long-term loss of employment
2 | Page
_____ Student has needs assistance with food or other bas
ic needs.
_____ Student needs assistance managing COVID related responsibilities at home (lack of a dedicated
computer, need to care for children/siblings/ill family members, etc.)
_____ Student needs assistance with childcare and health care.
Other: Please
explain:_____________________________________________________________________________
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.
The Golden LEAF Scholarship Program
Photograph and Publicity Release Form
I
, ______________________________, hereby give my college, the North Carolina
Community College System (NCCCS) and Golden LEAF, permission to use my name,
likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos,
video recordings, audiotapes, digital images, and the like, taken or made on behalf of Golden
LEAF Scholarship activities. I agree that the NCCCS has complete ownership of such
pictures, etc., including the entire copyright, and may use them for any purpose consistent with
the organization’s education missions. These uses include, but are not limited to illustrations,
bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and
any promotional or educational materials in any medium now known or later developed,
including the Internet.
I
acknowledge that I will not receive any compensation for the use of such pictures, etc., and
hereby release the NCCCCS, Golden LEAF and its agents and assigns from any and all
claims which arise out of or are in any way connected with such use.
I
have read and understood this consent and release.
I
give my consent to the North Carolina Community College System (NCCCS) and Golden
LEAF to use my name and likeness to promote the Golden LEAF Scholarship program,
education, and/or their activities.
____
_______________________________________ __________________
Signature date
____
_______________________________________ ___________________
Parent/Legal guardian (if age 17) date
I
do not give my consent to the North Carolina Community College System (NCCCS) and
Golden LEAF to use my name and likeness to promote the Golden LEAF Scholarship
program, and/or their activities.
___________________________________________ __________________
Signature date
____
_______________________________________ ___________________
Parent/Legal guardian (if age 17) date
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The Golden LEAF Scholarship Program
Photograph and Publicity Release Form
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Student Application North Carolina Community Colleges and Golden (Coastal Carolina Community College)

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Completed 3 February 2021

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