Parent Information Name of Parent(s)/Guardian(s) With which parent does student normally reside? Mother Father Both Other
Did either parent/guardian (living in the home) graduate from a 4-Year College or University? Yes No Mother Father Both If yes, which college?
Family Size Please list the names of your other children and the school and grade they are in: Please answer questions 1 and 2 below. 1. TAXABLE INCOME: Using line 43 on IRS form 1040 or line 27 on form 1040A, please indicate your TAXABLE INCOME (taxable income is usually quite a bitt less than gross and adjusted gross incomes). $
2. Number of individuals living in household
Please check any services your family receives: ADC (Aid to Dependent Children) Free school lunch Reduced school lunch Food Stamps None of the services listed
Student Information
School Name Grade Year of Graduation (yyyy)
Legal Name: Last First Middle
Social Security Number Date of Birth (mm/dd/yyyy) Phone
Current Address: Street / P.O. Box
City State Zip
Is the student a U.S. citizen? Yes No If not, what is his/her green card number?
Is the student: Male Female
What is the student's cultural background? American Indian Asian Hispanic/Latino Black/African American Native Hawaiian White
Applicant Name Date Applicant Signature (if submitting hard copy) Date Note: Electronic submission of this application confirms your signature
In accordance with Title IX of the Educational Amendments of 1972, Section 504 of the Vocational Rehabilitation Act of 1973, and Title VI and VII of the Civil Rights Acts of 1964, Southwestern Community College does not discriminate on the basis of disability, sex, race, color, religion, or national origin in its educational programs, activities, admission procedures, or employment practices.
Direct comments or questions to: ets@swcciowa.edu