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Student Cover Sheet
Baccalaureate Social Work Program
Tennessee State University
Name
T Number
Address
Cellphone
Are you a
Veteran?
□ Yes □ No
Email
Ethnicity:
□ Black
□ Caucasian
□ Hispanic
□ Multiple
□ Other
□ Verizon □ AT&T
Cellphone
Carrier
□ T-Mobile □ Sprint
□ Boost □ Cricket
□ Other _______________
□ 17 - 24
□ 25 - 32
□ 33 - 40
□ > 40
Have you
ever been
convicted of
a felony?
□ Yes □ No
If yes, did the felony involve
domestic violence, minors,
drugs, or alcohol?
□ Yes □ No
□ Male
□ Female
□ Other
Are you a
transfer
Student?
□ Yes □ No
How Many Credits Complete
at Transfer?
Have you
completed an
Associate
degree?
□ Yes □ No
School Name
Have you
completed a
Bachelor
degree?
□ Yes □ No
School Name
Do you currently
receive financial
aid?
□ Yes □ No
□ Pell/Federal Grants
□ Federal Loans
□ State Grants
□ TSU Scholarships
□ Other Scholarships
□ Other
Estimate
your total
volunteer
hours
completed
to date:
Emergency
Contact:
Name
___________________
Relationship to Student:
□ Parent □ Spouse
□ Other
Cellphone
Age:
Gender:
2014-08-17
Address
Effective Fall 2014