Perkins Application Form - John A. Logan College

Name *

First

Last

Semester *

JALC ID Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Phone *

Alternative Phone

JALC E-Mail Address *

Personal E-Mail Address *

Birth Date *

Sex *

High School *

Program of Study/Major *

Are you a U.S. Citizen? *

Are you a Veteran? *

Are you currently receiving a Pell Grant or public assistance? *

Ethnic Classification (for statistical purposes only) *

To be eligible for Perkins support, you must meet one of the following criteria, and be able to provide verifying documentation. Please check all that apply *

Disability
Economically disadvantaged family, including low-income youth and adults
Preparing for a non-traditional field
Single parent, including single pregnant women
English language learner
Youth that is in, or have aged out of, the foster care system
Homeless
Youth with a parent on active duty in the armed forces
Out of the workforce

How did you hear about the Perkins program? *

Orientation
Return participant
Instructor
Student referral
Advisor/Counselor
Staff referral
Program referral
Marketing materials
Other

Assistance you are requesting *

Books
Uniforms
Tool kit
Equipment
Other

In the space below, please provide a description of your situation. Include what obstacles you have that could prevent you from successfully completing a certificate or degree program. *

POLICY AND RELEASE OF INFORMATION FOR THE SPECIAL NEEDS OFFICE:

The information on this form is confidential and will help determine eligibility for the Perkins Grant.

Perkins loans are limited each year based on eligibility.

Students must file a FAFSA. First-time Perkins grant recipients must meet with the Accessibility & Resource/Perkins Grant Coordinator at the beginning of each semester. The Office of Financial Aid and the Accessibility & Resource Office will determine eligibility based upon the FAFSA.

I declare that the information given here is true and correct to the best of my knowledge. I authorize the Accessibility & Resource Office access to my student records, including academic records and financial awards and any other information pertaining to my enrollment at John A. Logan College. I understand that Perkins has limited funding and completion of this application does not guarantee that I will be awarded funding through the Perkins Grant.

Agree to the Policy and Release of Information

I Agree to the Policy and Release of Information for the Special Needs Office