Student Application Form (Page) - Take Stock In Children

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Who We Are
Get Involved
Contact
Students
Mentors
Donate

Who We Are
Get Involved
Contact
Students
Mentors

Student Application

Fill out the form below or Download the 2022-2023 Student Application

Student Information - Step 1 of 8

Student Name *

First

Middle

Last

Date of Birth *

Social Security # *

Student ID *

School *

Grade *

Student Phone *

Student Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address Same

Check if mailing address is same as home address

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

How do you (the student) identify?

Gender *

Male
Female
Gender Diverse

Student Race *

American Indian/Native American
Asian
Black/African American
Multiracial
Pacific Islander/Hawaiian
White
Other

If Other Please Specify *

Student Ethnicity: Is the Student of Hispanic, Latinx, or Spanish origin? *

Yes
No

The Florida Prepaid College Foundation Scholarship Requirements:

Does the student have a Social Security #? *

Yes
No

Are you (the student) a U.S. Citizen? *

Yes
No

Is the student a resident alien? *

Yes
No

Does the student have a Florida Prepaid College Foundation Scholarship Plan? *

Yes
No

Parent/Guarian 1

Parent/Guardian *

Parent Social Security #

Parent Phone # *

Parent Email *

Parent Date of Birth *

Last Grade Completed in School *

Parent/Guarian 2

Not applicable to student

Parent/Guardian (2)

Parent Social Security # (2)

Parent Phone # (2)

Parent Email (2)

Parent Date of Birth (2)

Last Grade Completed in School (2)

Applicant lives with *

Mother
Stepmother
Grandmother
Guardian
Father
Stepfather
Grandfather
Ward of Court
Other

If Other Please Specify

Number of brothers *

Number of sisters *

Please list all persons living in the home other than student/applicant (new line per person): *

Name / Age / Relationship / Highest Level of Education

Independent siblings living outside the home (new line per person):

Name / Age / Relationship / Currently Attending School / Last Grade Completed

Employment Information

Parent/Guardian (1) Current Employer

Name of Parent/Guardian (1) *

Employer *

Occupation

Address of Employer *

Address Line 1

City

State

Zip Code

Number of Years with Current Employer

Gross Monthly Salary

Before taxes and deductions.

Employment Information

Parent/Guardian (2) Current Employer

Name of Parent/Guardian (2)

Employer

Occupation

Address of Employer

Address Line 1

City

State

Zip Code

Number of Years with Current Employer

Gross Monthly Salary

Before taxes and deductions.

Financial Information

What is your household income? *

Are you eligible to receive any social services? (TANF, SNAP, Medicaid, etc.) *

Yes
No

Please check the services you currently receive.

Welfare/TANF
Food Stamps/SNAP
Medicaid

Are you currently receiving assistance from your local CareerSource Development Office? *

Yes
No

Do you currently receive income from any other source for this student/applicant? (Social Security, child support, unemployment, etc?) *

Yes
No

If yes, please list type of support and amount per month.

Do you or the student/applicant have a savings account? *

Yes
No

Approximate balance?

Do you own your own home? *

Yes
No

If yes, what is the amount of your monthly payment?

If yes, how much did your house cost?

Do you rent your home? *

Yes
No

If yes, what is the amount of your monthly rent payment?

How long have you been at your current address?

Upload Tax Return *

A complete copy of the most recent filed tax return Form 1040 must be attached with the student applicant listed as a dependent on the tax return in order to be eligible for consideration. (If you did not file taxes, please contact your local TSIC program).

Student Information

To be completed by student.

List activities, interests, strengths, hobbies, awards you have received

Church, school, community, work experience, etc.

Student Statement

Please tell us about your goals, aspirations and hopes for your future.

Is there anyone in particular you would like to match with?

Parent/Guardian Statement

To be completed by parent(s)/guardian.

Apart from financial considerations, how could this program benefit your child?

Please include your goals, aspirations, and hopes for your child's future.

Please list situations that might be relevant to school success

Serious illness in the family, loss of employment, Department of Children and Families involvement, homelessness, etc.

The factors listen below are used to determine your eligibility. Please check all that apply. *

Student attends a low-performing school (D or F rated school)
Single Parent
Incarcerated Parent
Deceased Parent
Absent Parent (no contact or support)
Poor relations between biological parents
Department of Children and Families involvement
Extended family in home
Extended family raising student
Student applicant is a teen parent
Parent was a teen parent
Family has received TANF benefits within past year
First generation college student
Student is first in the family to complete high school
Migrant worker
English not spoken in home
Loss of employment
Home in foreclosure
Homeless or living with extended family or friends
Serious illness in household
Disabled student or family member
Student is or has been in foster care
Other

If Other, please specify:

Signatures

I understand that the information contained in this application is accurate and will be managed and implemented by the Local TSIC Lead Agency/TSIC Program and shared with the Local Lead Agency selection committee. I also certify thgat all information in this application is truthful and accurate and that I understand that any false information in this application may result in my child losing his or her eligibility in the program.

Student Signature *

Date *

Parent/Guardian Signature *

Date *

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