Bridge Program Enrollment Form - SC State University

1.

Student Information

First Name
Middle Name
Last Name
Gender
Date of Birth	Day	Month	Year (YYYY)
Phone
Mailing Address
Apt # (If apllicable)
City
State
Zip Code
Email Address
Completed number of Midland Technical College credits (if none, list 0)
Anticipated # of Midland Technical College credits before transferring
Have you ever applied to SC State University before?
What is your major at Midland Technical College?
Intended SC State University Major
Term student plans to enter SC State University in

2.

Referral Information

Complete this section with your advisor if you are a current student at Midland Technical College and plan to transfer to SC State University at least one semester from now.

Advisor Name
Date	Day	Month	Year (YYYY)
Department at Midland Technical College
Contact Information - Phone
Advisor Email

*3.

I authorize SC State University and Midland Technical College to share my information with one another, including but not limited to academic transcripts, grades, and courses. This information may be used for reverse transfer of hours to Midland Technical College for completion of an associate’s degree.

Students served by the program begin their academic studies at Midland Technical College. These students will transfer to SC State University in junior status after earning their associate degree at Midland Technical College.

By electronic signing and submitting this form, I acknowledge that I have read, understood, and agreed to its terms and conditions.

Printed Name