Great Expectations Enrollment Sheet

Step 1 of 6

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Application Information

Name(Required)

First

Last

Have you applied and received a student ID number from TCC?

Yes, I have a student ID number

No, I don't have a student ID number yet

Student ID(Required)

Date of birth(Required)

MM slash DD slash YYYY

Current Age

Please enter a number from 1 to 150.

Gender

Male

Female

Race

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number (primary)(Required)

Phone Number (alternate)

Preferred Email Address(Required)

Emergency Contact Information

Emergency Contact Name

First

Last

Emergency Contact Relationship

Emergency Contact Phone Number

Residence Status

I am(Required)

Currently in foster care

Formerly in foster care

In a group home

Living independently

Date last in foster care (if you're not sure, an estimate is ok)

MM slash DD slash YYYY

Social Worker's Name(Required)

First

Last

Social Worker's Phone Number(Required)

DSS District(Required)

Which of these barriers may interfere with you completing school or getting a job? (Please check all that apply)

Child care

Transportation

Housing

Income

Work schedule

Medical issues

Ex-offender

Poverty

Other

Describe your other barriers(Required)

Authorization to Release Information

I, ________________________________________, (student’s name) authorize Tidewater Community College, Great Expectations staff, to provide information concerning my program status, attendance, and third party sponsor payment to:

• The appropriate state/local community agencies in order to obtain assistance to support my participation in the Great Expectations Program.
• The person/persons listed on my Great Expectations Application as my Great Expectations Emergency Contact and Home Contact.

This authorization will remain in effect until I successfully complete all aspects of the Great Expectations program. The information will be used by the program staff to assist me as I work towards completion of a degree program and complete a successful transition from school to work/post secondary education/etc. This information will not be shared with others. I also authorize the Great Expectations staff to contact the appropriate agencies to obtain information concerning my foster care status (date in care, case manager, DSS, Etc.) and to help in the transition from foster care to post secondary enrollment. This information is confidential and will not be shared by Tidewater Community College without my written consent.

By typing my FULL NAME below, I accept the Authorization to Release Information and sign this document.(Required)

Date

MM slash DD slash YYYY

Participant Commitment

I have discussed the Great Expectations Program at Tidewater Community College with the Coach for the Program and I am interested in participating. Participation means that I will:

• Apply for Financial Aid (FAFSA)
• Adhere to the TCC attendance policy
• Take the college placement tests if applicable
• Provide all requested paper work and complete all assignments in a timely manner
• Participate in TCC orientation program
• Participate in Great Expectations program orientation
• Participate in at least one leadership activity and be an active participant in all aspects of the Great Expectations Program
• Make full use of the Academic Advising resources available at TCC
• Meet with my Great Expectations Coach at least once a month
• Maintain regular contact with my Great Expectations coach for one year upon completion of the program

By typing my FULL NAME below, I accept the Participant Commitment and sign this document.(Required)

Date

MM slash DD slash YYYY

Image Release Form

I hereby consent to the use by the Great Expectations Program, Tidewater Community College, and it’s Foundation, of the name portrait, picture, video, audio or computer generated image of __________________________________________ for publication or promotional purposes at any time and from time to time until Tidewater Community College Marketing and Public Relations Office is advised in writing of the revocation of this authorization.

By typing my FULL NAME below, I accept the Participant Commitment and sign this document.(Required)

Date

MM slash DD slash YYYY

Type the characters from the image below