2023 Patsy Takemoto Mink Education Support Award Application

REQUIRED APPLICANT CRITERIA: Applicants must meet all criteria below, as posted on our website. Please review all criteria prior to submitting your application. In short, applicants must meet all of the following conditions:

must be a woman, at least 17 years of age;
must be a mother, with minor children;
must be pursuing a first degree at a postsecondary level of education (e.g., vocational, associate's, bachelor's, master’s, doctoral) AND degree program must add to level of education already completed (e.g., bachelor's after associate's, or advanced degree after a bachelor's);
pursuit of degree/certificate must be at an institution that does not discriminate on the basis of sex/gender; race/ethnicity; lgbtq+ status/identity; religion; disability; immigration status;
must be enrolled full time for the 2023-24 academic year in a not-for-profit, accredited institution or program in the U.S.. The Foundation uses the institutional definitions as defined by the Department of Education. Use the College Navigator interface on the website of the National Center for Education Statistics to look up your institution and determine if it is not-for-profit;
must be low-income: all annual family income less than $20,000 for a family of 2; less than $24,000 for a family of 3; less than $28,000 for a family of 4.

INSTITUTION IN WHICH YOU ARE ENROLLED IN 2023-24*

NAME OF INSTITUTION - DO NOT ABBREVIATE - IN WHICH YOU WILL BE ENROLLED IN 2023-24

I wish to proceed to the Patsy Takemoto Mink Education Support Award Application*

CONTINUE TO APPLICATION

Thank you for your interest in the Patsy Takemoto Mink Education Foundation.

Unfortunately, the institution you have entered is a for-profit institution.

As noted above and posted on our website, applicants must be enrolled in a not-for-profit, accredited institution or program in the U.S. during the 2023-24 academic year.

If you do not know if your institution is not-for-profit, try this helpful tool at https://nces.ed.gov/collegenavigator or contact your institution directly.

ALL APPLICANTS - PLEASE READ

IMPORTANT NOTES ABOUT:

SAVING TO CONTINUE YOUR APPLICATION AT A LATER TIME
SUBMITTING YOUR APPLICATION
POST-SUBMISSION EDITS

The ACCURACY of YOUR EMAIL ADDRESS is CRITICAL to these processes. PLEASE ENSURE IT IS ENTERED CORRECTLY.

TO SAVE & CONTINUE YOUR FORM AT A LATER TIME: You may continue to work on your application-in-progress over time until August 1 without formally submitting. Here are the necessary steps:

Scroll to the bottom of the Application and CLICK THE "SAVE & CONTINUE LATER" BUTTON.
A JotForm window will pop up asking you to Save Your Progress.
SELECT THE "Skip Create an Account" option at the very bottom of the pop-up window (DO NOT create a personal JotForm account).
A new window will pop up stating: "Your form has been saved as a draft.If you want to continue your form later, please enter the email address you would like to send the link to."
ENTER YOUR EMAIL ADDRESS, then CLICK "SEND LINK" Button to the right. If you do not complete this step you will not be able to complete your application in progress and will need to begin again.
You will receive an email at the address you provided, with your dedicated session ID link for your application-in-progress. SAVE THAT EMAIL. You will need that link to access your application-in-progress until you formally submit in full.
You MUST HIT THE "SAVE & CONTINUE" BUTTON in each subsequent session in which you enter new information but do not submit. If you do not either Save or Submit the application in full during that session any new information entered will not be retained.

SUBMISSION OF YOUR APPLICATION: Formal submission of your application occurs when you hit the SUBMIT button and not before, regardless of any information saved pre-submission. NOTE: All fields marked with a red asterisk* are required fields.

POST APPLICATION SUBMISSION EDITS: Once you formally submit your application you will receive a confirmation email that your application has been submitted to the Foundation, along with a NEW LINK for any post-submission edits.

CHECK YOUR SPAM folder if you do not recieve the emails noted above in your Inbox. Emails are sent only on Save for Later or Submission. If you did not receive an email you did not complete the Save or Submit step.

CRITERIA AFFIRMATION*

SECTION 1: Applicant Information

FIRST Name*

MIDDLE Name

LAST Name*

YOUR E-Mail Address:*

Confirmation EmailEmail address of the APPLICANT

YOUR Residential Address:*

Street Address

Address Line 2 (Apt #, Floor, etc.)

CityState

Zip CodeCountry

Is your Mailing Address the same as your Residential Address above?*

YesNo

YOUR Mailing Address (if different from Residence):

Street Address

Address Line 2 (PO Box, Apt #, Floor, etc)

CityState / Province

Postal / Zip CodeCountry

YOUR Phone Number:*

Enter your phone number including area code

YOUR Birth Date*

MonthDayYear

Age*

YOUR Social Security Number*

I have a SS# or ITINI do NOT have a SS# or ITIN

Last Four (4) Digits of YOUR SS# or ITIN

As of July, 2023, what is the HIGHEST EDUCATION LEVEL / CREDENTIAL you will have COMPLETED*

Details of COMPLETED Degree / Credential above

Ex:GED, Certificate Type, Discipline of degree (ex: BA in Philosophy, Masters in Social Work, PhD in Biology, etc)

DATE you COMPLETED the Degree / Credential above*

MonthDayYear

SECTION 2: Enrollment Information 2023-24

INSTITUTION IN WHICH YOU ARE ENROLLED IN 2023-24*

NAME OF INSTITUTION IN WHICH YOU WILL BE ENROLLED IN 2023-24 - DO NOT ABBREVIATE

INSTITUTION Website*

example: https://windward.hawaii.edu/

INSTITUTION Mailing Address:*

Address

Address Line 2

CityState

Zip Code

Date You FIRST ENROLLED in Institution Above*

MonthDayYear

Institution's 2023-24 ACADEMIC YEAR START DATE*

MonthDayYear

What DEGREE / CREDENTIAL are you seeking*

Specific Degree Detail*

Ex: Certificate Type, Discipline of degree (ex: BA in Philosophy, Masters in Social Work, PhD in Biology, etc)

DATE YOU EXPECT to achieve degree level/credential sought:*

MonthDayYear

INSTITUTIONAL CONTACT Name*

Institutional Contact FIRSTInstitutional Contact LAST

TITLE of Institutional Contact listed above:*

Example: Administrator, Registrar, Adviser...

E-MAIL of Institutional Contact listed above:*

PHONE # of Institutional Contact listed above:*

Enter Institutional Contact Phone # including area code

CAMPUS ADDRESS of Institutional Contact listed above:*

Address

Address Line 2

CityState / Province

Postal / Zip Code

SECTION 3: Financial Information

2023-24 TUITION Amount ($):*

Enter Amount in Dollars ($)

OTHER education-related EXPENSES in 2023-24 ($):*

Enter total Dollar Amt of Other Education-related Expenses, followed by itemization0/50

Have you applied for funding from other sources?*

YesNo

OTHER FUNDING SOURCES you have applied to (one line for each source):*

For tax purposes, ARE YOU A DEPENDENT?*

YesNo

Enter the ANNUAL INCOME of the PERSON WHO CLAIMS YOU as DEPENDENT:

Enter Amount in Dollars

YOUR MONTHLY INCOME, list all sources (one line for each source):*

Do OTHERS CONTRIBUTE to the HOUSEHOLD INCOME?*

YesNo

OTHER HOUSEHOLD INCOME, list all sources (one line for each source):

YOUR MONTHLY RENT/MORTGAGE:*

Enter Monthly Rent/Mortgage in Dollars

SECTION 4: Household and Personal Information

How many individuals live in your household, including you?*

# of individuals living in household

How many children do you have?*

# of children

Do your children live with you?*

YesNoSometimes

Enter the ages of your children living with you:

Separate by comma

Your Race/Ethnicity:*

Applicant's race/ethnicity

Disability of Applicant or Dependent*

Disability of applicant and/or dependent(s)

SECTION 5: Professional/Educational References

Please provide complete information for two professional or educational references such as an employer, supervisor, union representative, teacher, mentor, or colleague.

Professional/Educational Reference #1

Ref 1 Name*

First NameLast Name

Ref 1 School or Business*

With what institution (school, business, etc) is reference #1 affiliated

Ref 1 Relation to applicant:*

How does reference #1 know you (employer, teacher, etc)

Ref 1 Email:*

Email address of reference #1

Ref 1 Phone Number:*

Phone # of reference #1

Ref 1 Postal Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Professional/Educational Reference #2

Ref 2 Name*

First NameLast Name

Ref 2 School or Business*

With what institution (school, business, etc) is reference #2 affiliated

Ref 2 Relation to applicant:*

How does reference #2 know you (employer, teacher, etc)

Ref 2 Email:*

Email address of reference #2

Ref 2 Phone Number:*

Phone # of reference #2

Ref 2 Postal Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

SECTION 6: Short-Answer Questions
Please respond briefly - in a few sentences, less than 100 words - to the following five (5) questions.Please provide complete information for two professional or educational references (e.g. employer, supervisor, union representative, teacher, mentor, or colleague).

1. Describe the program in which you are/will be enrolled this year:*

0/200

2. How did you decide on the educational pursuit?*

0/200

3. What was your educational experience up to now?*

0/200

4. What are your educational goals?*

0/200

5. What will an Educational Support Award help you accomplish?*

0/200

SECTION 7: Short Essay

In approximately 500 words, tell us what else you would like us to know about your personal and educational history.*

Drag bottom right corner of text box to expand0/1000

Current Date*

Date

Verification*

2023-24 Education Support Award Application