AC Perks Program Application

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Please fill out the following application to apply to be a part of the AC Perks Cohort. Participants must be in a Career or Technology field (health careers, some programs in Business; technology and workforce; graphic arts; and sound recording technology) in order to be considered. Assistance is given on a first come, first served basis. For questions regarding your application or the program, please contact the Office of Student Success & Inclusion at access@angelina.edu.

Email *

The funds for this program are provided by the Carl Perkins Grant. In order to provide all possible student services to Perkins selected student populations, do you meet any of these categories? (Check all, if any, that apply.) *

Individuals with disablilities

Individuals from economically disadvantaged families, including low-income youth and adults.

Individuals preparing for non-traditional fields

Single parents, including single pregnant women

Out-of-workforce individuals

English learners

Homeless individuals described in the McKinney-Vento Homeless Assistance Act

Youth who are in, or have aged out of, the foster care system

Youth with a parent who is a member of the armed forces or is on active duty.

Required

Student ID Number: *

First Name: *

Last Name: *

Gender Identity: *

Male

Female

Non-binary

Prefer not to say

Email (the one you use most often): *

Phone Number: *

Major: *

GPA: *

In how many courses are you currently enrolled? *

In which area are you requesting assistance? *

Gas Mileage Reimbursement (for students 20+ miles away from either campus or clinical location)

Child Care

Program kit/tools

Bus Pass

Please check that you understand that as a participant of the program, you are required to contact or visit your assigned Success Coach once a month and complete the exit survey at the end of the semester. *

I will see or contact Annie Allen, Dir. of Student Access & Inclusion, once a month.

I will complete the Perks Program Exit survey at the end of the semester.

Required

If you are requesting child care assistance, which daycare provider do you currently use?

If you are requesting child care assistance, what is the name(s) of your child(ren) in child care?

If you are applying for child care assistance, please provide the name, phone number, and email address of the person AC will need to contact in order to get payment started:

In 500 to 700 words, please complete the following prompt: "I feel I am a worthy candidate for the AC Perks program because..." *

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