Sidewater Scholarship Application Form

Full Name *

First Name Middle Name Last Name

Birth Date *

Month Day Year

Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Indicate which training program you are interested in attending (choose one): *

Please indicate reason(s) for taking the training (choose all the apply): *

Email Address *

example@example.com

Cell Phone Number

Please enter a valid phone number.

Home Phone Number

Please indicate Ethnic Background

American Indian African American/Black Asian/Pacific Islander Hispanic White Other

Please Indicate Gender

Referred by

Are you currently employed *

Yes No

If you are employed, will this training help you retain your job?

Yes No

If you are employed, will this training help you receive a better wage?

Yes No

If you are employed, please indicate your Employer's Name and Address below:

Please indicate your annual income

I hereby promise that all of the information entered on this application is accurate and truthful to the best of my knowledge. I understand that any false statement can invalidate my candidacy for scholarship assistance.

CONSENT TO RELEASE INFORMATION I understand that my personally identifiable information in my education records is protected from disclosure under the Family Educational Rights and Privacy Act (“FERPA”) with certain exceptions. By signing and submitting this application, I consent to the disclosure by the College of all information contained within this application to the the Fund Sponsor for purposes of evaluating my application. I understand I may revoke this Consent upon providing written notice to the College. I further understand that until this revocation is made, this consent shall remain in effect. I further consent that if I am awarded a scholarship, the College and the Fund Sponsor may publicly announce and/or acknowledge my participation in this scholarship program in support of their marketing and fundraising efforts.

I also understand that I will be asked to report employment outcomes within 3 months of completion of the program.

Signature

Clear

Date