PROGRAM APPLICATION FOR GATEWAY TO COLLEGE ADMISSION

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1 PROGRAM APPLICATION FOR GATEWAY TO COLLEGE ADMISSION Please read the entire application carefully before completing. Print clearly. Use a black or blue ink pen. Only complete applications will be considered. Today s Date Applying for: Fall Semester Spring Semester Year Application Deadline Last Name First Name Physical Address City, State, ZIP Student Information Middle Initial Apt # Student Home Phone Student Address Student lives with Alternate Contact ( ) Name: Relationship: Phone(s) Parent Cell Parent Work # Additional Contact Phone(s) Student Cell Student Work # Contact Name & Cell Ethnicity (check one) Date of Birth Contact Name & Cell White/ Caucasian Asian/ Pacific Island / / Current Age Black/ African American Gender (check one) Hispanic/ Latino Male Native/ American/Alaskan Female Other (specify) Birthplace City State Country Language(s) Spoken at Home First language Second language Academic Information Your School District Currently enrolled in School? Yes No If yes, which high school? If no, give date of last attendance High school credits earned Grade: Student Name Page 1 of 6

2 (Please attach a transcript from each high school attended.) List all high schools, alternative programs, or home school where you have taken courses, beginning with the most recent. Use a separate sheet if more space is needed. School Location (City, State) Dates of Attendance # of credits earned Grade level when last attended Example High School Example, TX 01/03-05/ th grade Emergency Contact #1 Full Name: Last First M.I. Address: Street Address Apartment/Unit # City State Zip code Primary Alternate Relationship: Place of Employment: Emergency Contact #2 Work Full Name: Last First M.I. Address: Street Address Apartment/Unit # City State Zip code Primary Alternate Relationship: Place of Employment: Work Employment Work status does not affect your eligibility as long as work hours do not conflict with class hours. This information will help South Texas College determine your schedule. Are you currently employed? No Yes (Part Time 3-20 hrs/wk) Yes (Full Time 21+ hrs/wk) Work Location: Work Supervisor Name: Student Name Page 2 of 6

3 OTHER Have you ever been dismissed or suspended from school or college for any violations of student conduct or safety? If yes, please explain. Are you currently court-mandated to attend school? If so, please provide copies of all legal documents. Do you have a 504 Plan or an Individualized Educational Plan (IEP)? If so, will you be requiring services outlined in one of these plans? Please specify. What career area(s) or college major(s) interests you? Is there anything that may prevent you from attending classes on a regular basis? Court/Judge: Transportation Child Care Illness Work Other, Specify What assistance and resources would you need to help deal with the things you listed above? Referral Information How did you learn about this program? Administrator Counselor (Name) (School ) (Name) (School ) Friend / Other Signature I certify that the information contained in my application is correct and complete. I understand if I have not provided accurate information or required application materials I may be denied acceptance for the upcoming semester with the Gateway to College program at South Texas College. If selected for the program, I agree to abide by the policies and procedures of the Gateway to College Program and South Texas College. South Texas College is an EOE. For special accommodations issues or an alternate format, contact South Texas College Disability Support Services at (956) Applicant Signature: Date: Student Name Page 3 of 6

4 STUDENT CONSENT TO RELEASE INFORMATION South Texas College shall follow all applicable state and federal laws, rules and regulations that apply to student records. All information contained in the college records which is personally identifiable to any student shall be kept confidential and not released except upon prior written consent of the student or upon the lawful subpoena or other order of a court of competent jurisdiction. I authorize South Texas College, or any third party it has approved, to record my image, voice on film via photograph, picture, and/or videotape. I further agree that any recording may be shared at the sole discretion of South Texas College, or any third party the college approves. I hereby authorize South Texas College to release confidential information about me contained in the college records. I also authorize my school district to release confidential information about me to South Texas College. Student Last Name First Name M.I. Date of Birth Release to (please select all that apply): South Texas College / Gateway to College Staff Sponsoring School District Name: Parent/Guardian/Support Person: Name Address Relationship Phone Number Name Address Relationship or Phone Number Agency (if applicable) Information that will be released through authorization of above signature: name, address and phone transcript of grades date of birth verification of attendance last high school attended and date test score and progress information disciplinary action date of graduation and program of study To indicate that you understand all of the above and the information that will be released, please sign below: Student Signature & Date: PLEASE READ CAREFULLY PARENTAL APPROVAL FOR RELEASE OF INFORMATION & ENROLLMENT IN GATEWAY TO COLLEGE PROGRAM (ONLY FOR STUDENTS UNDER 18 YEARS OLD) I hereby grant permission to enroll in the Gateway to College program at South Texas College. I understand that the exact length of time to earn a high school diploma varies by a student s course load and credit needs. Gateway to College is not a fast-track program for high school completion. It may take a student 18 months to 3 years to receive a high school diploma through the Gateway to College program. Students will earn college credit toward an associate degree or earn an associate degree through the Gateway to College program. Students may remain in the Gateway to College program only until they earn a high school diploma or reach 25 years of age. Parent / Legal Guardian (please print name & relationship): Parent / Legal Guardian Signature & Date: Student Name Page 4 of 6

5 APPLICATION FOR ADMISSION ESSAY Directions: This Essay portion of the application helps us become acquainted with you on a more personal level and is an important step in the final acceptance of the Gateway to College Selection Committee. Your application is not complete without this typed essay and will not be considered for acceptance without receiving it by your announced deadline. Each topic includes questions you can ask yourself to help you write your essay. Each answer should be at least (2) two paragraphs per topic per page. If you do not have access to a computer, you may come by the Gateway to College office. Please type your name and the date on each page. Attach the Application for Admission Essay to your completed application. Essay Topics: 1. Your Strengths What personal strengths have helped you to achieve goals, survive life s challenges and/or to get back up and keep trying? What strengths have helped you to make friends and/or to make positive relationships with adults? What strengths have helped you to say no to peers who try to distract you from your goals in life? 2. Problems and Challenges What are some key personal problems or challenges that have interfered with your success in completing your education in the past? (i.e. attitude, behavior, motivation, skills, feeling accepted, cultural barriers, etc.) What would be different now? Describe your commitment & motivation to overcome these challenges at this time in your life. How will the strengths you described above help you to overcome your challenges and to be successful? 3. Your Interest in Gateway to College Tell us why you are interested in being part of the Gateway to College Program at South Texas College. (Why do you think this program is a good fit for you to achieve your goals? Why should the Selection Committee choose you for this scholarship-based program especially since there is a lot competition for limited slots? Explain each area.) 4. Your Motivation As a full-time college student, how would you balance your schoolwork, with other commitments you might have such as employment, family, social, and personal life? What would motivate you to attend classes 100% of the time? Explain all areas. Plagiarized essays will not be considered. Student Name Page 5 of 6

6 COUNSELOR APPROVAL FORM Entering Semester: FALL SPRING YEAR Date: Student Information Name: D.O.B Age: Phone # Alternate Phone # To Be Completed By High School Counselor Transcript o attached o faxed o mailed o other TAKS Results & Profiles Special program Participation Approved by: (Counselor Signature) Counselor Phone: High School: School District: (Counselor Printed Name) Fax: Counselor * For additional information Abril Teran (Student Resource Specialist) Mail correspondence to: South Texas College, Gateway to College, P.O. Box 9701, McAllen, TX GATEWAY TO COLLEGE STUDENT ELIGIBILITY REQUIREMENTS Prospective student must have this form completed and signed by referring/approving counselor. Prospective student is at least 16 years of age and no older than 20 years old at the time of application or by the first day of class. Prospective student must complete graduation requirements by the age of 21. Prospective student must reside and be enrolled in one of the participating school district boundaries. Student Name Page 6 of 6

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