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Last Name *
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First Name *
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EPCC Student ID #
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If you've been assigned an EPCC Student ID #, please provide it.
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Date of Birth *
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Mailing Address *
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City *
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State *
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ZIP/Postal Code *
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Telephone Number *
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Alternate Telephone Number
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Email Address *
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Gender
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Resident Status *
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What is your resident status?
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High School *
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What high school did you graduate from, or plan to graduate from?
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Major *
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Which major do you plan to declare, or currently pursue at EPCC?
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Enrollment Status *
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Student Type *
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First-Generation College Student *
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Are you a first-generation college student?
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Summer Attendance *
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Will you be attending EPCC for the summer sessions?
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Developmental Math *
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Are you currently or have you ever been enrolled in a developmental math class at EPCC?
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Non-Traditional Student *
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A Non-Traditional student is described as a student usually over the age of 25 who did not continue to college right after completing high school.
Are you a Non-Traditional student?
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U.S. Veteran *
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Are you a U.S. Veteran?
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U.S. Veteran Dependent *
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Are you a dependent of a U.S. Veteran? (Spouse or Child)
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Active Duty Relation *
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Is your spouse or parent active duty military?
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Police Officer Relation *
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Are you an immediate family member of a Police Officer?
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Nursing Clinical *
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Are you enrolled in the clinical portion of the LVN or RN program?
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Disabilities Registration *
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Are you registered with the Center for Students with Disabilities at EPCC?
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Attending Transmountain *
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Will you be taking classes at the Transmountain Campus?
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Dual Credit *
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Have you taken any Dual Credit Classes?
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Leadership
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Please list any leadership roles. (Incoming Freshmen Only.)
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Volunteer Positions
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Please list any volunteer positions. (Incoming Freshmen Only.)
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Essay *
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What are your goals in your field of study and after graduation? Why do you deserve this scholarship? Please write about any other factors that you would want the committee to consider.
Maximum length: 1,200 words.
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Reception Attendance *
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A scholarship reception will be hosted during the spring/summer semester (s). Students who receive a scholarship will be contacted and requested to attend. The recipient, along with one guest of choice, will be complimentary. If you do not attend the reception, you may deemed ineligible to receive a scholarship, unless you have extenuating circumstances that will prevent you from attending.
If you receive a scholarship do you agree to attend a reception?
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Photo Agreement *
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An EPCC photographer will be taking individual pictures at the scholarship reception.
Do you agree to be available before the reception for my photograph to be possibly taken?
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Photo Publication Agreement *
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If your photo is taken at a scholarship related event/reception or institutional event, do you authorize publication of the picture/audio?
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Testimonial Agreement *
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If you receive a scholarship do you agree to provide a testimonial during the scholarship reception or at other times deemed necessary to support the donor (s) and/or an organization if requested?
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Thank You Letter Agreement *
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If you receive a scholarship, do you agree to acknowledge the donor by writing a "thank you" letter?
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Correctness Certification *
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I certify that the information on this application is complete and correct and understand that the submission of false information is grounds for rejection of my application and withdrawal of offer(s)?
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Information Release Permission *
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I hereby give permission for this information to be released to the donor or potential donors of any scholarship. Furthermore, I authorize the publication of any award I may receive.
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Information Release Understanding *
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I understand that this authorization to release information is voluntary and will remain in effect until I revoke it in writing.
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Transcript Permission *
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I grant permission for an Administrator to obtain an unofficial transcript.
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Attachments
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