Student Name:_______________________________________________________________________________________________________________________________________
Street/P.O. Box Address_______________________________________________________________________________________________________________________________
City:_________________________________ Zip Code:__________________ Social Security #:____________________
Home telephone number:______________________________ Work Telephone #:_________________________________
Number of completed WC quarter credit hours:_______________________
Number of completed WC semester credit hours:______________________
Number of completed transfer credit hours:__________________________(circle quarter or semester hrs)
Current cumulative grade point average:_____________________________
I am currently a (please select one): ( ) Learning Support Student ( ) Freshman (30 semester hours) ( ) Sophomore (30+ semester hours)
I anticipate being a student at Waycross College for the following number of semesters: ( ) one ( ) two ( ) more than two
Have any extenuating circumstances taken place since filing of the Free Application for Federal Student Aid Form? If so, please elaborate (use back if necessary):
I understand that to be eligible for funding from the David Johns Fund for Students with Learning Disorders I must submit a Free Application for Federal Student Aid Form and the above information prior to consideration. I give permission to the Director of Student Services, the Coordinator of Testing, Counseling, and Student Development, and the Learning Disorders Fund Committee to review my financial standing. I understand that this information is confidential within the Review Committee.
_______________________________________________________________
Signature/Date
If you disagree with the finding of the Committee, you may appeal to the Director of Development and Community Services in writing within five working days.
(FOR OFFICE USE ONLY) FEDERAL FINANCIAL AID #:_____________
Approval for partial funding? ( ) Yes ( ) No ( ) Need additional information
Funding level approved:________
Initials and date of signature of Committee Members:_______________________