HCOP High School Summer Program Application

HCOP High School Summer Program Application

HCOP Summer Program Application

Student First Name*

Student Last Name*

Date of Birth*

Gender*

Select

Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Name of Parent or Guardian*

Parent/Guardian Phone Number*

What high school do you attend?*

What grade are you in?*

Select

What year will you graduate high school?*

Student Grade Point Average:*

If you have taken the SAT or ACT, please indicate your scores.

List any college courses you have taken and the grade you received.

Program Interest

Primary Discipline*

Select or enter value

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

Race & Ethnicity

Please answer the following questions about your race, ethnicity, and whether you belong to an underrepresented minority group.

Race*

Select or enter value

Ethnicity*

Select

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

Please indicate whether you a citizen of the United States.

U.S. Citizen*

Yes

Resident Alien 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.

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

Family Size

Select or enter value

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.

Send me a copy of my responses

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