24-25 Application for ACS

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Program Application

Please fill out all questions in the application.

Student Information

First Name:

Last Name:

Preferred Name:

Preferred Pronouns:

Phone #:

Jefferson State E-mail:

A #:

Personal E-mail:

Date of Birth:

Age:

Address:

City:

State:

Zip:

County:

Are you a Veteran?

Yes

Do you have a disability?

Yes

Do you identify as LGBTQ+?

Yes

How did you hear about our program?

Family Status

Marital Status

Married

Separated

Divorced

Widowed

Single without dependent children

Single with dependent children

Female Head of Household?

Yes

Number of Dependents:

Names and ages of dependent children:

Education

Employment and Income

Are you currently employed?

Yes

Have you had any income changes in the last year?

Yes

Income Reporting Instructions:

1. Check the box to the left for your household size (# of people in your home).

2. In the box to the right, type in your household TOTAL income.

Low Income
80% of Median
Income

Very Low Income
50% of Median
Income

Extremely Low Income
30% of Median
Income

Household
Size

Greater than
50% of the
Median Income,
but not over 80%
of the Median
Income

Greater than
30% of the
Median Income,
but not over 50%
of the Median
Income

Less than or
Equal to 30%
of the
Median Income

Applicant
Household
Income

52,850

33,050

19,850

60,400

37,800

22,650

67,950

42,500

25,820

75,500

47,200

31,200

81,550

51,000

36,580

87,600

54,800

41,960

93,650

58,550

47,340

99,700

62,350

52,720

Race/Ethnicity

Please select one or more to describe your Race and/or Ethnicity.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Hawaiian or Other Pacific Islander

White

Authorization

The Adult College Services is a free service offered to adult, non-traditional students and prospective students at Jefferson State. ACS seeks funding from off-campus sponsors to provide these free services (coaching, scholarships, textbooks, etc.) to its participants.
Adult College Services is responsible for the proper use of the funds which are received from its sponsors and must have the records (procedural and financial) reviewed as well as submit monthly, quarterly, and annual reports.
Please indicate your authorization for the following:

To the best of my knowledge, all of the information provided herein is true, accurate, and complete.

I agree

I authorize review of my Adult College Services records to be accessed by any scholarship sponsor or funding agency for the purposes of audit, promotion, and/or reporting.

I agree

Please complete the electronic signature by typing your name into the box below. This is in lieu of a handwritten signature.

Type Full Name

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