PARTICIPATION AGREEMENT FORM


  • First Name*
  • M.I.*
  • Last Name*
  • Date of Birth*
  • Gender*
    Male
    Female
    Prefer Not to Answer
  • Race*

    American Indian or Alaskan Native Asian or Pacific Islander
    Black, not Hispanic White, not Hispanic
    Hispanic More than one race
    Other Prefer not to answer
  • Email*
  • Phone Number*
    ### - ### - ####
  • Permanent Address*
    Street Address
    Address Line 2
    City
    State / Province / Region
    Postal / Zip Code
  • Mailing Address (if different from permanent address)
    Street Address
    Address Line 2
    City
    State / Province / Region
    Postal / Zip Code
  • Please select all the terms you plan to attend in the upcoming year.
    Fall 2019
    Spring 2020
    Summer 2020
    Fall 2020
  • Please select the MN Reconnect participating institution you would like to attend.*
  • What was the last college you attended?*
  • I request to participate in the MN Reconnect program.*
    I agree.
  • I give permission to my college, MN State, and the Minnesota Office of Higher Education to share information and documentation with each other as it pertains to the MN Reconnect program and to verify information provided on this agreement.*
    I agree.
  • I certify the information on this agreement is true and correct and I promise to provide additional documentation if requested.*
    I agree.
  • I understand not all MN Reconnect participants will receive scholarship awards and all scholarship awards are subject to the availability of funds.*
    I agree.
  • I understand I must submit a FAFSA or MN Dream Act Application to be eligible for a scholarship award.*
    I agree.
  • If I receive a scholarship award, I understand that changes to my FAFSA, State Aid Application, Pell Grant, MN State Grant, or state, federal, or other financial aid may cause an adjustment to my scholarship award.*
    I agree.
  • I certify I have read and understand the Notice to Participants.*
    I agree.
  • Signature (type full name)*
  • Date*