You must have JavaScript enabled to use this form. Required fields are marked with an asterisk '*'. Name * First * Middle Last * Email * Phone * Home Address * Address * City/Town * State/Province * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code * Have you lived in North Carolina for over 1 year (and have documentation to demonstrate you are a NC resident)? * Yes No Not Sure Are you a United States citizen? * Yes No What is your visa/immigration status? Are you currently working with young children? Yes No Please provide the name of the center or school where you work. Are you a current or former student at A-B Tech? Yes No Please provide your student ID number (if you remember it). Have you previously taken EDU-119 and passed with grade of A, B, or C? Yes No If you have taken any other EDU courses, please list the courses you have completed with a grade of A, B, or C. When do you anticipate being able to start the 2-semester scholarship program? August 2024 January 2025 Some time later If you participate in the program, would you need a laptop computer? Yes No Please tell us how you learned of this scholarship opportunity Director/Supervisor Program Flyer Outreach from A-B Tech Coworker or friend Other
