HSTA Waiver Maintenance & College Update Form

This form is required to be completed by all HSTA Scholars who wish to continue receiving or to defer the Health Sciences & Technology Academy Undergraduate, Graduate, or Health Professions Fee Waivers.  This form must be submitted each year between November 1st and March 1st as well as any time that you transfer, re-enroll, or change status.  Your information will be secured through encryption. Inother words, unauthorized individuals will not have the ability to retrieve your information. I give HSTA permission to include my GPA and test scores for program evaluation purposes. My name will not be included in this data.

1. Contact Information

First Name 
Last Name 
Middle Initial 
Parent/Guardian's Street Address 
Parent/Guardian's City 
Parent/Guardian's State/Province 
Parent/Guardian's Zip/Postal Code 
Parent/Guardian's Home Phone 
Student's Street Address 
Student's City 
Student's State/Province 
Student's Zip/Postal Code 
Student's Home Phone 
Student's Alternate Phone   Cell   Work   Other
Student's E-mail 
Student's Alternate E-mail

2, Do you plan to attend college during an upcoming academic term?

Yes No         

3. If you are not planning to attend college during the upcoming year, or have graduated, please choose one of the following options:

Completed a degree or certificate and not pursuing a further degree in the near future
Choosing to work instead
Enrolled in military
Academic or financial aid suspension
Other (please describe in Comments section below)

  1. If you are currently not attending college or vocational or training school, please describe you current employment (employer name, job title, state where you are working)?
Job title:   
Employer:
City:          
County:     
State:        

4. Do you plan to use the HSTA Undergraduate Waiver, HSTA Health Professions Fee Waiver, or the HSTA Graduate Waiver during the upcoming academic year?

Yes No

5. College Information

  1. What is the name of the college or school you are most likely to attend in the upcoming academic year?


  1. Are you enrolled at the college listed above for the upcoming academic year?

Yes No

  1. Please indicate your college status for the UPCOMING academic year by choosing one of the following options:

New student
Continuing student
Re-enrolling
Transferring

  1. Please indicate your college rank for the UPCOMING academic year by choosing one of the following options:

Freshman
Sophomore
Junior
Senior
Graduate School
Professional School
Doctoral Program
Associate's or Certificate Program

  1. Enter your Intended, or Current, Major in the space provided below.

  1. Select the type of degree you plan to receive:

Certificate    Associate's Degree   Bachelor's Degree   Master's Degree   Doctoral Degree

  1. If graduated, enter the month and year that you completed your degree or certificate program:

-- mm/yyyy

  1. Enter the name of your expected degree or certificate program:


  1. What is your most recent college OVERALL GPA?

  1. Please provide additional comments or information that may be helpful or your suggestions for the program:


 
Copyright © 2005 [Health Sciences & Technology Academy (HSTA)]. All rights reserved.
Revised: 10/02/05