Special Populations Program - CTE Student Support Application

The Strengthening Career and Technical Education for the 21st Century Act (Perkins V).

Please choose a semester:

General Information

Student's Legal First Name

Student's Legal Last Name

Student ID Number

Street Address

City

State

Zip Code

Home Phone Number

Cell Phone Number

myCCTC Email Address:

Gender

Date of Birth

Ethnicity

Marital Status

Do you have any dependents?

YesNo

Number of Dependents

Number of Dependents in Daycare

Number of Dependents in After-School Care

Child(ren)'s Name, DOB, and Gender:

How did you hear about this program?

Educational Information

Highest Education Level

List all degrees, certificates, and/or diplomas received:

Current Student Status:

Major:

Cumulative GPA:

Employment & Income Information

Employment Status:

If employed, list the company's name, your job title, and # of years worked.

Years as a homemaker with no substantial job outside the home:

Years of paid part-time employment:

Years of paid full-time employment:

Approximate gross family income:

Indicate approximate income amounts from the sources below, as applicable, per month:

*Note: Do not leave any items blank. Enter "0" for all answers not applicable.

Employment:

Vocational Rehabilitation:

AFDC:

Child Support:

Veteran's Benefits:

TANF:

WIA Grant:

Unemployment:

ABC:

Social Security:

Pell Grant (per semester):

Food Stamps:

Lottery:

Work Study:

Other:

How many miles (round trip) do you drive from your home to college each day?

Perkins V Special Populations Categories

Please select any of the following that apply to you:

If on a computer, hold "Ctrl" and click to select more than one.

If other, please explain:

Please provide any additional information about your needs:

Career Goals & Requested Services

Briefly describe your career goals (what you would like to be doing five years from now) and how completion of your current program at Central Carolina Technical College can assist you in achieving these goals:

Almost done! Please read the content below.

The Special Populations Program at Central Carolina Technical College is funded through The Strengthening Career and Technical Education for the 21st Century Act (Perkins V).

All of the information on this form is true and complete to the best of my knowledge. Any information which might be used for statistical purposes may contain my name, but will not be released to the general public.

I authorize Central Carolina Technical College to consult with and release any pertinent data to support services, prospective employers, and/or training personnel on my behalf.

By clicking the "Submit" button below, I am agreeing to the terms and conditions with in this form