Student Name ____________________________________ Datatel ID: _____________________
Address ________________________________________________________________________
City/State/Zip ____________________________________________________________________
Phone ___________________________ E-mail ________________________________________
Emergency Contact Name _________________________________________________________
Emergency Contact Phone ______________________ County of Residence ________________
High School Year Graduated __________________
I hereby apply for participation in the Williamsburg Promise program. I understand that to receive Promise
funding I must:
Complete applications for Title IV funding and be awarded all financial aid funds for which I am eligible
Meet twice a week with my mentor and provide any documents required by my mentor
Maintain Satisfactory Academic Progress
Meet any and all payment arrangements that may be required for past due balances.
I affirm that I am a Williamsburg County resident or have graduated from a Williamsburg County High School,
and have disclosed any student loan defaults or overpayment of funds to any institution. I understand that
failure to disclose any sources of funding, or any balances owed may result in loss of Promise participation and
funding, which may result in my owing a balance to Williamsburg Technical College. I understand that this is a
pilot program and may be cancelled at any time during the academic year.
Student Signature ________________________________________Date_____________________
Continuing Student New Student Re-admit
Admitted by __________________ Date ________________
Coded to Datatel By ________ Date ________________
Student Advised by __________________________ Date _______________
Mentor Haynes Weiss
Gentry Yearty By _______________ Date ________________
(Based on COL103 assignment)
Promise Recipient By ______________________ Date ________________
Declined Reason ____________________________ By____________ Date______
Notes _________________________________________________________________
______________________________________________________________________
