Pontiac Promise Zone Scholarship Application Part 1

2021-2022 Academic Year

Fill out this form if you are a SENIOR in high school or have graduated high school or received your GED to provide background information. NOTE: This is not the entire application. You MUST fill out PART 2 in order to complete the scholarship. This application is intended for students who have never applied for the PPZ scholarship. If you have previously registered for the scholarship, please fill out the "Part 2". DO NOT APPLY MORE THAN ONCE. IF YOU MAKE A MISTAKE, DO NOT APPLY AGAIN. THIS WILL DELAY YOUR APPLICATION. PLEASE CALL 248-214-0456 TO FIX YOUR MISTAKE WITH ADMINISTRATION.

Authorization and Sign Off

I hereby authorize any school, skilled trades, certificate, and apprenticeship program that I am enrolled in that participates in the Promise Zone Scholarship, through its agents and employees, to release any of my financial aid, attendance, demographic, and/or academic record information, in whole or in part, to the Pontiac Promise Zone Executive Director, Program Coordinator, or Administrative Assistant, to facilitate the analysis of my scholarship eligibility and the subsequent educational and economic impact of this scholarship. As a recipient of a Pontiac Promise Zone scholarship, that award informant becomes part of my educational record. By consenting to receive any scholarship amount awarded to me, I agree to allow the release of this information in my educational record to third parties specified under the Family Education Rights and Privacy Act (FERPA). FERPA affords certain rights to students concerning the privacy of and access to heir educational records to third parties. While this form authorizes my school, in conjunction with Pontiac Promise Zone, to release educational record to third parties, it does not obligate either entity todo so. My school reserves the right to review and respond to requests for release of my education records on a case-by-case basis. For additional information, I can visit the U.S. Department of Education's website at: https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html

I also authorize the Pontiac Promise Zone to use information regarding my scholarship in promotion of the Pontiac Promise Zone scholarship.

This release is starting on the date of the signature on this agreement and after scholarship receipts for statistical purposes. To rescind this Authorization of Release, I understand that I must submit written notification of rescission to my school. I will also notify the Pontiac Promise Zone in writing of my decision to rescind my authorization. This rescission would result in the termination of my receipt of the scholarship.

My signature (or that of my parent/guardian if I am under the age of 18) below indicates that I have read and understand this Authorization of Release, and that I authorize the release of my educational records as described above.

By agreeing below indicates that I have read and understand the terms of the Pontiac Promise Zone scholarship. I further confirm that I will/have provide(d) all of the information requested, to the best of my ability, including verification of my current permanent address and all relevant school attendance prior to graduation. I understand that this information will be verified by the PPZ and school partners, and any mistakes and/or misrepresentation will result in denial and/or revocation of the PPZ scholarship. I also agree to allow PPZ to share my information with other scholarship organizations. If any information changes, please notify the Pontiac Promise Zone via phone, 248-214-0456, or email, ppzscholarship@gmail.com. Type your e-signature below. Provide Parent/Legal Guardian signature if you are under the age of 18.

Electronic Signature (If an applicant is under the age of 18, please enter parent or guardian's name).

Student ID

Electronic Signature via Date Stamp

Thank you for your application!