HCOP Pre-Matriculation Student Application

Student First Name*

Student Last Name*

Date of Birth*

Gender*

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Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Current BC Student*

Yes

No

Student ID*

Student's Present Campus*

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Student Grade Point Average:*

Program Interest

Primary Discipline*

Please select the Allied Health Career you are interested in pursuing.

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The federal agency providing funding for this grant is requesting the following information.

Ethnicity*

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Race*

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Familial Educational Background

In order to determine whether you qualify as a first-generation college student, please provide the educational history of you parents or legal guardian.

Mother's Name

Father's Name

Guardian's Name

Citizenship/Immigration Status

Are you a U.S. Citizen*

Yes

No

If Resident Alien, Provide Registration Number

Birthplace (City, State, Country)*

Financial Information

If you wish to be considered under the criteria of "Low Income," we need to know how much was your parent's or your total household income from your most recent federal income tax return form.

Proof of income must be provided along with the HCOP application by submitting a copy of your federal income tax form or social security benefits in order to be considered for admission.

All information provided becomes the property of the Broward College Health Careers Opportunity Program and will remain confidential.

Family Size

Please enter the total family size as indicated on your most recent federal tax return.

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Annual Income

Please indicate your or your parent's annual income bracket. This includes the total household income including TANF, child support, alimony, pension, etc.

Are there any family circumstances, health, or special problems, which may be useful for us to know in evaluating your application?

By submitting this application to participate in the Health Careers Opportunity Program (HCOP), funded by the U.S. Department of Health and Human Services, I hereby certify that all the information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any falsification or misrepresentation of information may result in disqualification from the program.

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