Promise Zone Recipient Renewal Application
Use this form to annually renew your Newaygo County Area Promise Zone scholarship. This form is due by June1. For questions, please contact us at firstname.lastname@example.org or by phone at (231) 924-8888, or visit http://promise.zone for resources and more information.
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Student Phone Number
Would you like to receive text message reminders from the Promise Zone to the phone number listed above? (Ex: Your scholarship renewal application is due on June 1)
Date of Birth
Important! All Promise Zone communication will be sent to this address.
I am attending:
An Approved Apprenticeship Program
I Have Not Attended Any College Programs Yet
I plan to attend:
Summer Semester (May 2018)
Fall Semester (August 2018)
Winter Semester (January 2019)
Fall Semester (August 2019)
I currently meet my college's Satisfactory Academic Progress policy:
I Have Not Attended Any College Courses Yet
Please attach your most recent college transcript. If it is currently unavailable, please submit this application, then send your transcript before June 30 using the Document Submission Form found on the Promise.zone website.
MCC Students: To access your transcript, login to the MyMCC Portal, then click on WebAdvisor for Students, click on Planning & Registration, then Student Planning and Registration. Once in Student Planning, hover the cursor over Student Planning, and click on the last option in the drop down box titled unofficial transcript.
Consent and Releases
I understand that the Newaygo County Area Promise Zone (NCAPZ) Board will be accessing student information from my local school district for the purpose of confirming eligibility to receive the Promise Scholarship. Under conditions specified in the FERPA regulations, 34 CFR Part 99, my school district may non-consensually disclose personally identifiable information from education records in connection with the financial aid for which I have applied or received; and for the purpose of administering the Promise Scholarship student aid program.
ELECTRONIC RELEASE AND CONSENT TERMS: I understand that the Newaygo County Area Promise Zone Board (NCAPZ) and the Newaygo County Regional Educational Service Agency (NC RESA) wishes to share information about the Promise Zone program and services with potential program participants, with the community in general, and for state and national reporting. With my permission, these materials may include images of me in print media, on broadcast media, online, or on other recorded media. I hereby consent that the NCAPZ and the NC RESA, and its entities, be authorized to use my portrait, picture, photograph, name, voice and/or image on video tape, audio tape or film, or any other reproduction of me and to distribute and/or exchange copies of these to promote their programs. No compensation is offered in exchange for permission. Promise Scholarship students must comply with the partnering institution's standards for Satisfactory Academic Progress to remain eligible. This form shall also serve as a release of information for academic records from my high school and post-secondary institution and allow the Newaygo County Area Promise Zone Authority Board to gauge use, and interest, for all scholarship dollars preserved within the Newaygo County Area Promise Zone campaign funds. By completing this form, I understand that this authorization will remain effective from the date signed until the Promise Scholarship Award term expires. I understand all information will be handled confidentially in compliance with all applicable federal laws. I also understand that I may see the academic information that is to be shared, and that I may revoke the authorization at any time by written, dated communication.
AUTHORIZATION TO RELEASE EDUCATIONAL RECORDS: I hereby authorize any school that I am enrolled in that participates in the Promise Zone Scholarship, through its agents and employees, to release any of my financial aid, attendance, demographic and/or academic record information, in whole or in part, to my local Promise Zone Authority/Organization coordinator, or his/her designee, to facilitate the analysis of my scholarship eligibility and the subsequent educational and economic impact of this scholarship. As a recipient of a Promise Zone educational scholarship, that award information becomes part of my educational record. By consenting to receive any scholarship amount awarded to me, I agree to allow the release of this information in my educational record to third parties specified under the Family Educational Rights and Privacy Act (FERPA). FERPA affords certain rights to students concerning the privacy of, and access to, their education records. While this form authorizes my school, in conjunction with the local Promise Zone Authority/Organization, to release educational records to third parties, it does not obligate either entity to do so. My school reserves the right to review and respond to requests for release of my educational record on a case-by-case basis. For additional information, I can visit the U.S. Department of Education’s website at https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html. The Promise Zone Scholarship can have several positive impacts on postsecondary enrollment, persistence, degree attainment and overall success in college. To understand these impacts, I authorize my postsecondary academic record information, in whole or in part, to be released back to my local Promise Zone Authority/Organization coordinator, or his/her designee, in adherence to FERPA for analysis to inform and improve the Promise Zone Scholarship program. I also authorize my local Promise Zone Authority/Organization to use information regarding my scholarship in promotion of the Promise Zone Scholarship. This release is authorized starting on the date of the signature on this agreement and after scholarship receipt for statistical purposes. To rescind this Authorization, I understand that I must submit written notification of rescission to my school. I will also notify my local Promise Zone Authority/Organization in writing of my decision to rescind my authorization. This rescission would result in the termination of my receipt of the scholarship. My signature (or that of my parent/guardian if I am under the age of 18) below indicates that I have read this Authorization to Release Educational Records form and that I authorize the release of educational records as described above.
Parent Signature (Required if student is below the age of 18)
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