Last Name

First

MI

Date of Birth

Address

City 

State Ohio Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Daytime Phone Number   (740/389-1212)  

Evening Phone Number   (740/389-1212) 

Cell Phone Number   (740/389-1212) 

Email address 

Are you a current student at Marion Technical College? No Yes

For which course are you requesting assistance? (List course name and or course number)

What term/section are you applying for? Term:   Section:

How do you plan to use your education when it is complete?

Obtain employment in healthcare   Continue my education in healthcare   Other, please describe

Are you currently working? No Yes If no, are you out of work due to downsizing layoffs termination

Other, please describe

Please write a paragraph 1) how this education will benefit you personally and 2) how you will use your education to benefit the community or the healthcare system.

Are you willing to participate in the follow-up evaluation program to help us determine the success of this project? No Yes

Are you willing to let us share your name, picture, and success stories with our sponsors:? No Yes
(You are not required to share personal information or stories to be eligible for assistance)

Do you have any disqualifying offenses? Click here for list. No Yes If yes, please speak with Carla Anderson at ext. 220 or e-mail at andersonc@mtc.edu for further information concerning eligibility. Please note: you will be required to submit a background check prior to acceptance.

Professional or employment status (check all that apply)

Employed for wages

Self-employed

Out of work and looking for work

Out of work and not currently looking for work

A homemaker

A student

Military

Retired

Unable to work

Do you have plans to seek work in healthcare after completion of the course?   Yes     No

If so, what position do you wish to obtain?  

Where do you plan to look for employment?

Within what time frame do you plan to look for employment?

All requests for assistance will be evaluated, and qualifying individuals will be asked to complete an interview with the grant administrator/program coordinator. Each individual must successfully complete a background check and proof of tuberculosis-free status and other health screenings (as required by the course) before assistance can be provided. Applicants are required to complete compass testing to show course readiness, and foundation courses may be required to ensure your success. Please click here for an estimation of the total program costs to determine your financial needs.

I give consent to provide FAFSA results to the grant administrator.

I give consent to share my name, picture, and success story with the grant sponsor (Marion Community Foundation).

Please be sure that you have completed and submitted the following:

1. MTC application
2. MCF grant application
3. FAFSA
4. COMPASS

You should receive a call from the grant coordinator as soon as the above steps have been completed. If you do not receive a call within 3 business days, please contact Sandra Allen at allens@mtc.edu or at (740) 389-4636 ext. 243

Signature:    Date: 00/00/0000