www.southeasterntech.edu
Southeastern Technical College is an Equal Opportunity Institution
Personal Data-Please Print Neatly
Social Security Number
Date of Birth (MM/DD/YY)
Last Name First Name Middle Name
Mailing Address
City
State
Zip Code
Email Address
County of Residence
Cell Phone
Home Phone:
Residency Information
Gender
Male
Female
Are you Hispanic/Latino?
Yes
No
Ethnic/Racial Group-Please select one or more races from
the following five racial groups
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Are you a U.S. Citizen?
Yes
No
If you answered No, do you have a VISA?
Yes
No
If you are NOT on a VISA, what is your country of birth/citizenship?
First Generation Student
Military Status
Did your father graduate from college?
Yes
No
Unknown
Are you a dependent of an active duty member, veteran, member of the national guard, or a reservist in the U.S.
Armed Forces?
Yes
No
Did your mother graduate from college?
Yes
No
Unknown
If Yes, please specify:
Active Duty
Veteran
National Guard
Reservist
Branch:
Air Force
Army
Coast
Guard
Marine
Navy
Program Information
Program of Interest-Please select “core” or list a specific
program of choice
Core
Other___________________________________
Semester and Year to Begin
Year: _____________
Fall
Spring
Summer
Campus
Vidalia
Swainsboro
Student Type
Beginning
Returning
Educational Data
Graduation Year
Current High School
Have you taken any of the following tests?-Check all that apply
PSAT
SAT
ACT
Accuplacer
Have you taken classes at another college? If so, where?
Emergency Contact
Name
Phone
Swainsboro Campus
346 Kite Rd, Swainsboro, GA 30401
(478) 289-2200
Vidalia Campus
3001 East First St, Vidalia, GA 30474
(912) 538-3100
Dual Enrollment Application for Admission
FERPA Release
Southeastern Tech is hereby authorized to release to my parent/guardian and to my home high school any and all records/information that is in my
permanent record at STC. I understand that my social security number, grades, tuition, fees, and other information are included in my permanent record at STC.
I understand that (1) I have the right not to consent to the release of my education records; (2) I have the right to receive a copy of such records upon request; and
(3) that this consent shall remain in effect until revoked by me, in writing, and delivered to Southeastern Tech.
Complete information regarding the Family Educational Rights and Privacy Act of 1974 (FERPA) can be found in the Southeastern Technical College Catalog and
Student Handbook.
Consumer Information
In compliance with federal law, Southeastern Tech is required to provide all prospective students with the opportunity to request data on crimes committed
on our campus and our College safety and security policies. This information can be obtained from the Southeastern Technical College Catalog and Student
Handbook on our website. Go to www.southeasterntech.edu, move your mouse over the Student Affairs tab, click on the Catalog & Handbook link and then on
Campus Security. Prospective students who wish to obtain a copy of this report and who do not have access to the Catalog and Handbook on the Internet may
obtain a copy by contacting: Dr. Barry Dotson, Vice President for Student Affairs.
The Technical College System of Georgia and its constituent technical colleges do not discriminate on the basis of race, color, creed, national or ethnic origin, sex,
religion, disability, age, political affiliation or belief, genetic information, disabled veteran, veteran of the Vietnam Era, or citizenship status (except in those special
circumstances permitted or mandated by law). This nondiscrimination policy encompasses the operation of all TCSG and technical college administered programs,
federally financed programs, educational programs and activities involving admissions, scholarships and loans, student life and athletics. It also applies to the
recruitment and employment of personnel and the contracting for goods and services. The Technical College System and Technical Colleges shall promote the
realization of equal opportunity through a positive continuing program of specific practices designed to ensure the full realization of equal opportunity.
The following individuals have been designated to handle inquiries regarding the nondiscrimination policies:
An individual with disabilities requiring assistance with publications, accommodations or activities of this technical college should contact: Helen Thomas,
Special Needs Specialist, ADA/Section 504 - Equity - Title IX (Students) - OCR Compliance Officer, Office 165, PH: (912) 538-3216
hthomas@southeasterntech.edu
An individual with questions or concerns about our nondiscrimination policy on the basis of sex in education programs and/or activities should contact: Lanie
Jonas, Director of Human Resources, Title VI - Title IX (Employees) - EEOC Officer, Office 138B, PH: (912) 538-3230
ljonas@southeasterntech.edu
Pursuant to O.C.G.A. 16-10-20, it is a felony to make a false statement on any document. In addition, making a false statement on this application may result
in your dismissal from the college.
AUTHORIZATION: I give Southeastern Technical College permission to contact me at the telephone numbers I have provided via any means, including text
message or voice.
I intend to abide by the rules and regulations of Southeastern Tech. By signing and submitting this application and upon my admission to Southeastern
Technical College, I understand that my name, quotations, and photographic likeness including video footage may be used in all forms of media for
advertising, trade, and any other lawful purposes on behalf of Southeastern Technical College or the Technical College System of Georgia and that I will not
receive, now or in the future, any compensation for this usage. I also understand that my name, quotations, and photographic likeness may be gathered
from and posted to STC’s social media sites and website. I also realize that during my training at STC, photographs may be taken of me for use in promoting
STC. I give my permission for the release of directory information as defined in the Catalog and Student Handbook. Unless I notify Admissions by filling out a
Directory Information Exclusion Form, I give permission for the above to be done.
Dual Enrollment Funding Waiver (To be completed by the parent/guardian)
I understand that my student, ____________________________________, will be receiving credit hours not all of which may be eligible for Dual Enrollment
funding available under Georgia law (HB 444). I acknowledge that I am responsible for keeping track of the number of credit hours attempted and/or earned by
my student in the Dual Enrollment program. If my student exceeds the maximum number of credit hours available, I agree to pay all tuition, mandatory fees, and
book costs that are not covered by the Dual Enrollment funding program out-of-pocket.
If my student is eligible for HOPE Grant or HOPE Career Grant funding, then I choose the following option (select one):
______I agree and authorize the technical college to apply the HOPE Grant and or HOPE Career Grant funds towards any credit hours not covered
by the Dual Enrollment funding program.
______I agree to pay out of pocket the tuition, mandatory fees, and book costs for any credit hours that are not covered by the Dual Enrollment and/or
HOPE Grant/HOPE Career Grant Funding programs.
As the parent/guardian of the above named student, my signature on this waiver certifies that I have read, understand, and accept the above information. I agree
to hold harmless and expressly waive any legal claims that could otherwise be made against Southeastern Technical College or the Technical College System of
Georgia with regard to any authorized actions taken by the technical college, or for any out-of-pocket payments made by me to enroll my student in Dual
Enrollment courses.
_________________________________________________________Date________________
_________________________________________________Date________________
Student Signature
Parent/Guardian Signature
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome