HSTA Waiver Maintenance & College Update Form

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          If "Yes" please list upcoming semester you plan to attend: 

1. If you are not planning to attend college during the upcoming year, 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)

2. Please describe your academic accomplishments to this point or during the current year:

Degree or Certificate Completed:     
Major Field of Study Completed:       
Degree Granting Institution:                
State Where Granted:                         
Month and Year Degree Granted:      
Second Major:                                      
Minor Field of Study:                            
Degree Honors (ie Magna Cum Laude, etc.): 
Student ID Number (Do not list SSN):
Final GPA:                                             

3. 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:        

3. 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

1. In addition to, or in place of the HSTA Undergraduate, Graduate and Health Professions Fee Waivers, please indicate the aid that you plan to use by selecting any of the following options that apply:

Promise Scholarship
Pell Grant
West Virginia Higher Education Grant
Other scholarships or grants
Student or family income and/or loans
Graduate Assistantship and/or graduate loans
Other sources (please describe in Comments section below)
 

4. College Information

1. Please list the college(s) you have applied to or are thinking about attending?

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

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

Yes No

4. Provide you Student ID Number for the school you are attending if different than your Social Security Number (do not list your SSN here):

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

New student
Continuing student
Re-enrolling
Transferring

6. 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

7. Enter your Intended Major in the space provided below.

8. Enter your Enrolled Academic Major according to your college in the space provided below.

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

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

10. Enter the month and year that you plan to complete your degree or certificate program:

-- mm/yyyy

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

12. What is your most recent college OVERALL GPA?

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

OPTIONAL: The following four questions are not required but would be extremely helpful to HSTA.  They are requested in order to complete a study comparing HSTA Scholars educational attainment and employment compared with their parents.  It will be kept confidential and no names will be used with the results.

What is your mother's highest level of education achieved?

What is your father's highest level of education achieved?

What is your mother's current job title if employed outside the home?

What is your father's current job title if employed outside the home?