High School Dual Enrollment Camp Opportunity Scholarships (DECOS) Application
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Non-discrimination Statement: Paul D. Camp Community College does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Human Resources Manager; 100 N. College Drive, Room 103, Franklin, VA 23851; 757-569-6708.
Please read through the questions on this application and prepare your answers before filling them in. You can hit the back button at the bottom of the page and it will save your answers temporarily. However, if you close out the application before you hit the submit button, your answers will not be saved. When you are finished filling out the application, make sure you press the submit button before leaving the application.
Check the primary location that you are or will be attending *
Have you applied for admission to the College?
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Do you intend to pursue a degree or certificate at Camp?
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Last Name
First Name
Date of Birth
年
/
月
/
日
Address
City
State
Zip Code
Telephone Number (Home, Work, Cell)
Name of High School
High School Address
City
State
Zip Code
Please indicate the type of high school diploma you plan to complete
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Intended Field of Study
Extracurricular Activities and Honors
I am currently in the Upward Bound Program and/or currently eligible for Free/Reduced Lunch at my high school and can provide proof upon request.
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Essay Instructions
If your scholarship requires an essay, please provide the information below.  If your scholarship does not require a specific essay, please tell us about a) your previous achievements, b) your financial need and c) your educational goals. Your essay must be 300-500 words, well-organized, proofread, and free of grammatical errors.
Please copy/paste your proofread essay into the space below
To Send In Additional Support Documentation:
Please email us at scholarships@pdc.edu with any additional paperwork needed, such as reference letters, transcripts, etc. References should speak to your academic and extra-curricular work, as well as your character. Please check the scholarship listing for any additional documentation required. Thank you.
Notice
I certify that the information I have provided in this application is true and complete to the best of my knowledge. I authorize the Office of Admissions & Records and the Office of Financial Aid to release information about me to the appropriate scholarship committee. I understand that I must complete the financial aid application process to be considered eligible for any scholarships. If I am selected for a scholarship, I authorize release of biographical information for use in publicity related to the scholarship and/or other information as needed for other marketing activities. (please enter your full name as your digital signature)
Digital Signature *
With whom do you live?
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Total Number of Persons Living in your household:
List name, age and relationship of each household resident to applicant. Include yourself.
Household Resident 1
Name
Age
Relationship to Applicant
Household Resident 2
Name
Age
Relationship to Applicant
Household Resident 3
Name
Age
Relationship to Applicant
Household Resident 4
Name
Age
Relationship to Applicant
Household Resident 5
Name
Age
Relationship to Applicant
Educational Completion of Parents or Guardians
Mother’s Name
Grades
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Mother’s Address (if different from student)
Mother’s Phone # (if different from student)
Father's Name
Grades
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Father’s Address (if different from student)
Father’s Phone # (if different from student)
Taxable Income
Use your last 1040, 1040-EZ or 1040-A Tax Form in completing this section. Please check the income range on the following scale that is reflected by your last year’s taxable income.

If you did not file a tax return, please provide non-taxable benefit/income information below.
Taxable Income
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Non-Taxable Income
If you did not file a tax return or if you receive any untaxed benefits/income, please list the annual amount shown on your last year’s End of Year Statement for all members of the family.

Documented proof of family income may be required to complete your application regardless of income source. Examples of income verification include: signed copy of parent/guardian
Child Support Received
Welfare Benefits (Do not include food stamps)
TAN-F
Social Security Benefits (untaxed only)
Worker’s Compensation
Veteran’s Benefits
To Send In Additional Support Documentation:
Please email us at scholarships@pdc.edu with any additional paperwork needed, such as reference letters, transcripts, etc. References should speak to your academic and extra-curricular work, as well as your character. Please check the scholarship listing for any additional documentation required. Thank you.
Any other untaxed income and benefits, such as Black Lung and Railroad, or Retirement Benefits.
Notice
I certify that the information I have provided in this application is true and complete to the best of my knowledge. I authorize the Office of Admissions & Records and the Office of Financial Aid to release information about me to the appropriate scholarship committee. I understand that I must complete the financial aid application process to be considered eligible for any scholarships. If I am selected for a scholarship, I authorize release of biographical information for use in publicity related to the scholarship and/or other information as needed for other marketing activities. (please enter your full name as your digital signature)
Parent/Guardian Digital Signature *
Date *
年
/
月
/
日
Student Digital Signature *
Date *
年
/
月
/
日
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