CONFIDENTIAL
PROJECT START APPLICATION FORM
Date:
Office use only:
Date Received ______________
Input in database ____________
Major:
Anticipated Graduate Date: _______________________
How did you hear about the Project Start program?
A. DEMOGRAPHICS:
Name:
K#:
(Last)
(First)
(MI)
Address:
PO Box:
City:
State:
Phone #:
Zip:
(H/C/W)
Sex:
Email Address:
Date of Birth:
Ethnic Origin: (Circle One) (optional)
Hispanic/Latino
American Indian or Alaska Native
White
US Citizen: (Circle One)
Yes
No
Is English your first language? (Circle One)
/
/
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
f no, explain
Yes
No
B. FAMILY/HOUSEHOLD INFORMATION:
Marital Status: (Circle One)
Do you have children?
Apt #:
Single/Never Married
Married
Separated
Yes
Divorced
Remarried
Widowed
No
If so, how many and what are their ages?
What are your childcare expenses per week? $
List all persons in household (family members, including self, relationship)
Name
Relationship
____________________________
__________________
____________________________
__________________
____________________________
__________________
____________________________
__________________
____________________________
__________________
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Age:
Do you have dependents not residing in your household? (Circle One)
Name
____________________________
Relationship
__________________
____________________________
__________________
Yes
No
C. EDUCATION:
Are you currently enrolled in a Technical Program at Kirkwood? (Circle One)
Will you be full time or part time next semester?
(Circle One)
Did you graduate from high school? (Circle One)
If no, have you received:
GED?
H.S. Alternative?
Last High School Attended:
Yes
Full-time
Yes
No
Yes
Yes
No
No
Name:
No
Part-time
Date:
Date:
Year Graduated: _________
Address:
City:
State:
Zip: ______
Additional Educational Training:
Name: ______________________________________________________
City: __________________________________ State:
Type of Training: _____________________________________________
Diploma, Certificate or Degree (Type and Dates)
_____________________________________________________
List any other educational training received:
**Note: If you have earned a Bachelor’s Degree, you will need to provide documentation detailing why
you cannot utilize that degree and why you need trained in another area.
Describe any help you may need in the following areas:
Subject
Describe
Reading
Math
Writing
Spelling
Study
Other
2
Please check areas in which you may need assistance:
Personal Counseling
Anxiety
Family/Parenting Concerns
Problem Solving Assistance
Stress Management
Time Management
Advising/Registration
Accommodations
Career Services – resumes, interviewing, etc.
Financial Aid Information
Student Advocacy
Other
D. EMPLOYMENT INFORMATION:
Employment Status: (Circle One)
Employed Full-time
Self-employed
Laid Off
Employed Part-time
Seasonally Employed
Not Employed, date last worked:
Work history (begin with current or most recent job & work backwards)
1.
(Employer)
(Date Started)
(Address)
(Hrs/Week)
(City, State, Zip)
____
(Date Left)
(Circle One)
Part-time Full-time
(Rate of Pay)
Job Title:
Reason for Leaving:
Describe Duties & Skills Used:
________________________________________________________________________
2.
(Employer)
(Date Started)
(Address)
(Hrs/Week)
(City, State, Zip)
(Rate of Pay)
Job Title:
Reason for Leaving:
Describe Duties & Skills Used:
3
(Date Left)
(Circle One)
Part-time Full-time
E. MEDICAL/HEALTH:
If you have a physical or mental disability that creates a barrier to your education, please explain below:
F. FINANCIAL:
Have you applied for a Pell Grant or other Federal Financial Aid? (Circle One)
Do you qualify for Pell Grant? (Circle One)
Yes
No
Yes
No
What circumstances are causing a financial need?
Family income: List all sources and amount of monthly income for all family members
(including alimony and child support received if applicable)
Household Member
Employer or
Monthly Income
Receiving Income
Benefit Program
Total year income
Benefits received: Do you or any family member receive any of the following benefits?
Benefit
Family Member
Amount
Length of Time Rec’d
FIP
___________________
Food Stamps
___________________
_______________
__________________
Title 19
___________________
_______________
__________________
SSDI - SSI
___________________
_______________
__________________
VA
___________________
_______________
__________________
General Assistance
___________________
_______________
__________________
_______________
__________________
Worker’s Compensation
__________________
Employer Name: _____________________________________
4
Unemployment
___________________
_______________
__________________
Employer Name: ____________________________________ When benefits end_______________
Other Assistance
___________________
_______________
Have you applied for funding from any of the following?
Date Applied
__________________
Name of Worker
Promise Jobs
_______________
________________________
Title 20 Blockgrant
_______________
________________________
Are you (or will you be) paying childcare costs for you children while attending college? (Circle One)
Average weekly amount paid for daycare:
Yes No
G. MISCELLANEOUS:
Are you a veteran?
Yes
No
If yes: Dates of service….From
Branch: (Circle One) Army
Type of Discharge:
To
Navy
Air Force Marines Coast Guard Reserves
H. REFERENCES:
Name three people not related to you who can provide a reference.
Name
Address
City
State
Zip
Phone
Years Known
Relationship
Name
Address
City
State
Zip
Phone
Years Known
Relationship
5
Name
Address
City
State
Zip
Phone
Years Known
Relationship
I. PLEASE ANSWER THE FOLLOWING: (you may type answers and attach document if you wish)
Why did you decide to attend college?
Why did you choose your current major?
Share a time in your life when you had to overcome a hardship:
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What have you liked most about being a college student?
What have you liked least about being a college student?
Tell me something you have learned about yourself since beginning classes at Kirkwood:
What sets you apart from other students?
7
We are required by the Foundation and Scholarship Donors to follow-up with our students until they are
employed in their chosen field. Please provide the name of two people who will know where you are in case we
lose track of you after you graduate:
Name:
Name:
Address:
Address:
Phone #:
Phone #:
Relationship:
Relationship:
J. SIGNATURE:
1. I give my permission to Kirkwood Community College's Project START staff to request information
regarding any support I may receive from other agencies listed on this application. This information
will be used for educational support purposes only, and will be kept strictly confidential.
2. If accepted into the program, I also give my permission for staff to contact faculty members to verify my
participation in class.
Student Signature
Today's Date
Return application to: Dean of Students Office
108 Iowa Hall
Kirkwood Community College
PO Box 2068
Cedar Rapids, IA 52406
April 2015
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