Educational Partnership Program Application

Your Name:*

First NameLast Name
Have you enrolled in TMCC?*

YesNo
NSHE ID (Student ID Number):*
Preferred Contact Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number:*
Please enter a valid phone number.Format: 000-000-0000.
Date of Birth:*
Gender:*

MaleFemaleOther
Are you Hispanic or Latino?*

YesNo
Ethnicity:*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More Races
Native Language:*
Marital Status:*

MarriedDivorcedWidowedSingleSeparated
Number of children (6 and under):*
Number of children (7 to 18):*
Do you need childcare?*

YesNo
Number of children needing childcare:
Educational Background and Eligibility
Do you have a High School Diploma / GED / HSE:*

YesNo
Have you submitted a FAFSA on StudentAid.gov?*

YesNo
Do you have a past due balance with any Nevada college?*

YesNoNot Sure
Do you have any student loan defaults?*

YesNoNot Sure
Do you have a pending financial aid appeal?*

YesNo
Have you taken classes for credit at TMCC or another college in the past?*

YesNo
TMCC Degree/Certificate/Emphasis You Are Seeking:*
How many credits have you accumulated at TMCC?*
Are you a veteran, active duty service member, or military-affiliated (spouse/dependent)?*

YesNo
Which are you?*

VeteranActive DutyMilitary Spouse/DependentOther
Eligibility Criteria
Check any of the following circumstances that apply to you:

Involved in the Justice SystemSingle parent with custody of my child(ren) at least 51% of the timeDisplaced homemaker (unemployed/underemployed, responsible for the home making duties, and previously dependent on someone else)PregnantSNAP (Food Stamps) recipientTANF (Temporary Assistance for Needy Families) recipientMedicaid / Medicare recipientWIC (Women, Infants, and Children) participantSection 8 or Public house recipientHomeless or couch-surfingPerson with Permanent or Temporary DisabilityHistory of substance abusePell Grant eligibilityEnglish Language LearnerPursuing a career traditionally occupied by a gender other than yoursYouth currently or formerly in foster careYouth with parents on active duty with the Armed Forces or National Guard
Justice System Involvement:*

Currently on parole or probationResident of NNTHCurrent participant in court programPreviously incarcerated
Please indicate the name of the court program:*
Permanent or Temporary Disability:*

Receiving SSI benefitsVA Disability recipientWorkers' Compensation recipientEligible through the Disability Resource Center (DRC)
My Strengths Are:*

Able to handle stressGood at budgetingHealthyMotivatedSober and cleanNone of the above
Resources I Have:*

Computer & Internet AccessReliable TransportationHealth InsuranceChild CareTime Management SkillsNo Legal ProblemsResources to Pay Tuition or TextbookSafe, Secure, and Affordable HousingA Support Network (Family & Friends)None of the above
Employment Information
Employment Status:*

UnemployedEmployed
Current Employer (if applicable):
Position:
How long employed:
Number of hours/week:
Income:
Do you need help finding a better job?*

YesNo
Tell us about yourself and the support you believe would help you succeed:*
Please share your story, educational goals, challenges, and how TMCC's Educational Partnership Programs can help.
How did you hear about us?*

TMCCDWSS (Welfare/ SNAP office)Parole & ProbationNDOCWashoe County Sheriff's OfficeNone of the aboveOther
Certification and Acknowledgment

By submitting this form, I understand that continued enrollment as a program participant comes with certain obligations. I agree to honor the participant responsibilities, policies and procedures as outlined in this Contract. I further understand that my acceptance as a participant in the EPP Program was based upon my expressed commitment to pursue a specific educational program of study. I hereby agree that the goal, completion date, and PEP are acceptable to me and realize that any change in the program of study must be submitted for review to my designated EPP Counselor who will discuss my case with the Educational Partnership team for approval.

I further realize that any change to the above may affect my continued eligibility for the program and may result in my disqualification as an Educational Partnership Programs participant.
Certification*

Yes, I understand the performance agreement.
Please verify that you are human:*
Sender Name:
Should be Empty:

Educational Background and Eligibility

Eligibility Criteria

Employment Information

Certification and Acknowledgment