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Race/Ethnicity

NOTE: The following questions adhere to the U.S. Department of Education standards for gathering information about a student's race and ethnicity.

Guidelines: 

• American Indian or Alaska Native (a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment).

• Asian (a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam).

• Black or African American (a person having origins in any of the black racial groups of Africa).

• Native Hawaiian or Other Pacific Islander (a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).

• White (a person having origins in any of the original peoples of Europe, the Middle East, or North Africa).

Are you of Hispanic/Latino descent (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture/origin, regardless of race)?

Additionally, what race(s) do you consider yourself? Regardless of your answer to the previous question, please check all box(es) that apply to indicate your race(s).

Please provide answers to the following writing prompts.

 

Responses must be between three (3) and four (4) complete sentences.  

ü  Income Verification

§  Tax Filers (one of the following):

□   2025 D-40 Processed Tax Return from the Office of Tax and Revenue (OTR) located at 1101 4^th Street SW

□   2025 D-40 Processed Tax Return Extension with 2024 Certified D-40 Processed Tax Return from OTR

§  Non-Tax Filers (one of the following):

□   12-month (Jan-Dec 2025) SNAP Statement

□   12-month (Jan- Dec 2025) Child Support Document

□   12-month (Jan- Dec 2025) Retirement/Annuity Document

□   12-month (Jan- Dec 2025) Social Security Disability Income (SSDI) or Social Security Income (SSI) Statement

□   12-month (Jan- Dec 2025) Unemployment Benefits or Worker’s Compensation Disability Statement

□   Ward of the Court Letter (dated for 2025)

ü  Residency Verification

§  Current Residency document (one of the following: not more than 45 days old with Name, Date and Address Portion)

□   Utility Bill (gas, water, cable, electric, land line phone) – no cell phone bills

□   Bank or Mortgage Statement

□   Pay Stub (Name, Date, and Address Section)

□   Statement from a Landlord or rental office letterhead, stating utilities are included in rent

You and your parent/guardian must sign below. By my/our signature(s) on this form I/we pledge that:

·         The statements made and circumstances represented throughout the application are truthful to the best of my/our knowledge.

·         The writing prompts accompanying this form are substantively the applicant’s work.

·         All residency and financial information I/we provided is accurate.

 

By my/our signature on this form I/we understand and agree that:

• The information submitted will be reviewed by The College Success Foundation Scholars Program staff and/or external partners for the purposes of selection.
• Prior to candidate selection, The College Success Foundation Scholars Program staff may contact school officials to confirm the applicant’s/student’s school attendance and conduct. The information may be considered in the selection process.
• Once selected for the program the student may be contacted by The College Success Foundation Scholars Program staff and asked to participate in program evaluations and student satisfactory surveys.
• If the information provided in this application is found to be false or inaccurate, it is sufficient to deny selection and participation in the program.

 

By my/our signature on this form I/we consent to:

The use of any and all information from this application in connection with CSF-DC research activities. The applicant’s individual transcript and financial information will not be made available to the public through CSF-DC research activities in a form that would allow the applicant to be identified. Research results that are made public will be aggregated or averaged to reflect the total student population and/or performance.

 

 

Student Certification Statement: The information I have reported on this application is, to the best of my knowledge, true and correct. I have accurately reported my academic and financial information; my activities, involvement, and responsibilities. I understand incorrect or incomplete information may jeopardize consideration of this application. I certify that I have shared the contents of this application form with my parent/guardian and he/she has granted permission to include their information. By signing below, I officially agree and give my consent to all the above terms and conditions of The College Success Foundation Scholars Program.

 

Parent Certification Statement:   I understand that my child is making application to participate in The College Success Foundation Scholars Program.  Further, I certify that the information I have reported on this application is, to the best of my knowledge, true and correct.   I certify that my child shared with me the contents of this application form, and I grant permission to include my information. By signing below, I officially agree and give my consent to all the above terms and conditions of the program.