Application for Services
Please complete this eligibility form completely. Students interested in becoming a member of the ACE Program must meet the eligibility requirements as set forth by the U.S. Department of Education. The University of Pikeville ACE Program will respond to let you know if you are eligible.
Student Information
(To be completed by Student)
Name
*
First Name, Middle Initial
Last Name
Student ID #
University of Pikeville Student ID
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
College Classification
First Time Freshman
Freshman, Attended Before
Sophomore (30+ hours)
Junior (60+ hours)
Senior (90+ hours)
College Sport
If applicable
Have your previously participated in one of the following TRiO programs? Please check the box(es) of any programs you have participated in.
Upward Bound
Education Talent Search
Student Support Services
Select the highest level of education completed by your parents.
Father (High School)
Father (Two-year college degree)
Father (Four-year college degree)
Mother (High School)
Mother (Two-year college degree)
Mother (Four-year college degree)
Were you referred for services?
Yes
No
If yes, who referred you?
Do you have a documented disability?
Yes
No
If yes, please explain.
Have you declared a major?
Yes
No
If yes, please list.
Release of information
I certify all information provided in this application to be true and correct. I authorize the ACE Program to access my further authorize the ACE Program to release my name and/or picture to provide recognition in all Student Support Services print and digital publications.
Student Signature
*
Please use your mouse or finger to sign your signature
Date of Signing
-
Month
-
Day
Year
Date
Submit
Should be Empty: