ACAP Application

Contact Information - Parent(s) / Supporter(s)

Parent or Legal Guardian Name

First NameLast Name

Student Name

First NameLast Name

Student Date of Birth

Date

StudentCell Phone

Please enter a valid phone numberFormat: (000) 000-0000.

Student Home Phone

Please enter a valid phone numberFormat: (000) 000-0000.

Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Email

example@example.com

Alternative Emergency Contact

Name

First NameLast Name

Relationship

Cell Phone

Please enter a valid phone numberFormat: (000) 000-0000.

Other Phone

Please enter a valid phone numberFormat: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Questionnaire

1. Why do you want to attend the ACAP program at South Arkansas Community College?

2. What are your goals for the future? Where do you see yourself in 10 years?

3. What kind of job would you like to have when you finish school? Why?

4. What are 3 things you are good at? 3 things you struggle with?

5. Are you on Facebook, Instagram, Twitter, SnapChat, or other Social Media? Do you check your account(s) regularly? ON your cell phone, the computer, or both?

IMPORTANT: ALL APPLICANTS MUST READ AND SIGN.

I certify that all information provided on this application and supplementary materials is correct and complete.
I understand that any untruthful or false statement in this application could result in my application being denied or my immediate dismissal from the ACAP program.
I understand that I am required to notify and update the ACAP program of any change in status, including (but not limited to) a disciplinary or criminal incident that occurs after submission of this application and prior to my enrollment in the ACAP program.

Signature