Perkins Grant Program - FDTC Needs Assessment

Please complete the following information and submit.
* denotes required field

*Student ID:
Please do not enter a social security number.
*Full Name (include Mr./Ms.):

Prefix:   *First:   Middle:   *Last:   Suffix:

*Street/P.O. Box
*City, State, Zip      
*Date of Birth:
*Gender:
*Employment Status:
*Ethnic Origin:
*Marital Status:
*Employer:
*Home Phone:

( ) - -

*Work Phone:

( ) - -

*Does either parent have a four-year degree?
*Do you have any special needs related to a disability?
*Student Status:
*If returning, how many semesters have you been at FDTC?

Self Assessment of Needs. Please check all areas for which you may need assistance while enrolled in the Perkins Grant Program.
I need tutoring in:
I would like counseling in:
I am interested in learning more about the following:
Program:
Who is your advisor?
Have you applied for Financial Aid? Yes   No
If so, what type of assistance are you receiving?
What are your specific career goals?
What are your academic strengths?
What are your academic concerns?
Do you plan to graduate? Yes   No
Do you plan on transferring to another college? Yes   No
Are there other concerns that may prevent you from remaining in school until you reach your educational goals?
By clicking on the Submit button at the bottom and checking this box, you agree to the following: I authorize the release of academic and/or financial records to the Perkins Grant Program. The information given is true to the best of my knowledge. If I request tutoring, I will meet with my tutor at scheduled times or notify the tutor or coordinator one day in advance. I will meet with the program coordinator at least one during the term to review my progress. I will participate in as many group workshops as my schedule will allow.