Perkins Student Application

1Student Information > 2Perkins Information
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
JWCC ID number (listed on student ID card)
Program of Study / Major
Phone Phone - ### - ### ####
Do you share this phone number with anyone?

Do you share this phone number with anyone? Yes No
If yes, who shares this phone with you?
Is it okay to text this number?

Is it okay to text this number? Yes No
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Which gender do you identify as?

Which gender do you identify as? Male Female Prefer not to answer Other Other
Please identify your racial / ethnic group (select all that apply).

Please identify your racial / ethnic group (select all that apply). Asian Black or African American Latino or Hispanic Native American White Native Hawaiian or Pacific Islander Choose not to respond/Unknown
How did you hear about Perkins?

How did you hear about Perkins? Orientation JWCC Website Another student A faculty / staff member Other program referral (TRiO, the Foundation, etc.) Other Other
Name of person or program that referred you: