Broward College Judson A. Samuels South Campus

All fields marked with * are required and must be filled.

The purpose of this Exit Form is to help TRIO SSS to learn about your whereabouts after Broward College and your career aspirations, so that we can work to continually improve the program.

1. First & Last Name

First NameLast Name

2. Enter your BC I.D. #

3. Enter Today's Date

mm-dd-yyyy

4. BC Email

Example@mail.broward.edu

5. BCID#

6. I am exiting the SSS Program because (Please check one):

7. If you have graduated enter your graduation date below.

mm-dd-yyyy

8. Degree Awarded. Check all that apply

9. Career Pathway. Please Select one.

10. If not graduating, why are you exiting (select all that apply)?

11. If transferring, what school will you be transferring to (Please Select One)?

12. Please enter your career goals below.

13. Enter your signature in the box below to confirm that you have read and agree with all of the above statements.

TRIO SSS South Exit Form