25-26 Application for Adult College Services

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Program Application

Please note: This application is for a free support program through Jefferson State's Adult College Services.

This is NOT an application for admission to Jefferson State Community College.

You will ALSO need to complete an admissions application if you are not already enrolled at Jefferson State, for credit courses.

You can do that through this link: Apply to Jefferson State for Admission

Please fill out all questions in the application.

Student Information

First Name:

Last Name:

Preferred Name:

Residency Status:

Phone #:

Alabama.edu Email:

A #:

Personal E-mail:

Date of Birth:

Age:

Address:

City:

State:

Zip:

County:

How did you hear about our program?

Family Status

Marital Status

Married

Separated

Divorced

Widowed

Single

Do you have dependents?

Yes

Are you a female

Head of Household?

Yes

Education

Employment and Income

Are you currently employed?

Yes

Total Household Income:

Has the household 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 that appears 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

53,700

33,600

20,150

61,400

38,400

23,000

69,050

43,200

25,900

76,700

47,950

28,750

82,850

51,800

31,050

89,000

55,650

33,350

95,150

59,500

35,650

101,250

63,300

37,950

Race/Ethnicity

Please select to describe your Race and/or Ethnicity.

Alaskan Native or American Indian

Hispanic or Latino/a

Black or African American

Hawaii or Other Pacific Islander

Asian

White / Caucasian

Multiple Race/Ethnicity

Other / Not Listed

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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