Step 1 of 5 20% Student InformationName* First Middle Last Gender* Male Female Student ID or SSN* Date of Birth* MM slash DD slash YYYY Age* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell Phone*Email* Does the student receive any special education services at their high school (such as an IEP or 504 plan)?* Yes No or prefer not to answer We understand the importance of meeting the unique needs of all students on an individual level. Will the student require any special support or accommodations from The Presidents’ Council during their time in the PC Scholars Program? (ex. including parents in all communications, monthly parent/student meetings with staff, accommodations during class sessions, etc.)Would you like to meet with us via video call to further discuss any such accommodations? Yes No Household InformationHousehold* Two Parent Single Parent Grandparent(s) Guardian Annual Household Income* Under 10k 10k-19,999 20k-29,999 30k-39,999 40k-49,999 50k-74,999 Above 74,999 Scholar StructureSee special language addressing grade levels for high school students entering into the program. SOPHOMORES - $1,500 JUNIORS - $750 SENIORS - SENIOR STIPEND INCENTIVE Parent/Guardian Information Mother/Guardian* First Middle Last Address(if different from above) Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home PhoneWork PhoneHighest Grade Completed* Grammar School High School Vocational School Some College 2 Year College Bachelor's Degree Master's Degree Doctoral Degree Professional Degree Email* Father/Guardian* First Middle Last Address(if different from above) Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home PhoneWork PhoneHighest Grade Completed* Grammar School High School Vocational School Some College 2 Year College Bachelor's Degree Master's Degree Doctoral Degree Professional Degree Email* Race/Ethnicity*American Indian/Alaskan NativeAsianAfrican American/BlackCaucasianNative Hawaiian/Pacific Islander Student's School InformationHigh School* High School Curriculum* College Prep General Vocational Anticipated Graduation Date* MM slash DD slash YYYY GPA*Please include a copy of your year-end report card High School Counselor's Name* First Last High School Counselor's PhoneHigh School Counselor's Email Career InterestsPlease select top three Career fields that interest you and rank them 1-3, with 1 being the highest interest.Business Administration General Business Entrepreneurship* *If interested in entrepreneurship, what field sparks your interest?Other career interest: Career Interests (cont.)Please answer the following questions completely.Extracurricular*List your extracurricular activities, special interests and hobbies. List each activity and indicate the corresponding grade level for each activity (7-10)Awards & Honors*List significant awards and honors you have received. List each award or honor and indicate the corresponding grade level for each (7-10).ExperienceList your employment and volunteer experiences.Position/Job Title Employer Employment Dates Position/Job Title Employer Employment Dates Essay QuestionsWhat are your plans after high school? What are your career goals?*Additional FilesPlease include a copy of your most recentyear-end report cardFileMax. file size: 32 MB.I understand that the information provided in this application is confidential and that it will not be disclosed to anyone who is not affiliated with the program. I certify that the information provided is accurate and complete. I further agree that if I am chose to be a participant int his program, I will participate in all of the sessions and activities provided.Student Name*By typing your name here, you certify that the information provided is accurate and complete. First Last Date* MM slash DD slash YYYY Parent/Guardian Name*By typing your name here, you certify that the information provided is accurate and complete. First Last Date* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
