SCHOLARSHIP APPLICATION For GATEWAY TO COLLEGE PROGRAM 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 Social Security Number Year Student Information Application Deadline Last Name First Name Physical Address City, State, ZIP Student Home Phone Student E mail Address Student lives with Alternate Contact ( ) Name: Middle Initial Apt # 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 Hispanic/ Latino Native/ American/Alaskan Gender (check one) Male 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 and last high school attended High school credits earned Grade: Student Name Page 1 of 7
(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 Ex: ABC High School Anywhere, TX 01/03 05/2004 2.5 9 th grade Grade level when last attended 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 El Paso Community 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 7
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. Court/Judge: What career area or college major interests you? Is there anything that may prevent you from attending classes on a regular basis? 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 to the Gateway to College scholarship. I also understand that I may not be enrolled in any high school or any other alternative high school education program while participating in the Gateway to College scholarship program. If selected for the scholarship, I agree to abide by the policies and procedures of the Gateway to College Program and El Paso Community College. EL Paso County Community College District does not discriminate on the basis of race, color, national origin, religion, gender, age or disability veteran staus, sexual orientation, or gender identity. For special accommodations issues or an alternate format, contact El Paso Community College Disability Support Services at (915) 831 2676. Applicant Signature: Date: Student Name Page 3 of 7
STUDENT CONSENT TO RELEASE INFORMATION El Paso Community 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 El Paso Community 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 El Paso Community College, or any third party the college approves. I hereby authorize El Paso Community 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 El Paso Community College. Student Last Name First Name M.I. Date of Birth Social Security # Release to (please select all that apply): El Paso Community 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 I hereby grant permission to enroll in the Gateway to College scholarship program at El Paso Community 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 may 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 21 years of age. Parent / Legal Guardian (please print name & relationship): Parent / Legal Guardian Signature & Date: Student Name Page 4 of 7
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. 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 survive 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 El Paso Community 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, employment, family, social, and personal life? What would motivate you to attend classes 100% of the time? Explain all areas. Student Name Page 5 of 7
THIS FORM SHOULD BE TAKEN TO THE LAST SCHOOL ATTENDED School District Information Form This form is being brought to you by a student who is applying for Gateway to College Scholarship program through EPCC. In order to assess whether Gateway to College can meet the applicant s educational needs, we are requesting their transcript and a copy of their Individual Education Plan (IEP) or 504 plans, where applicable. Applicants who have an IEP (or 504) can only be accepted to Gateway to College after an IEP meeting is held. A EPCC representative must be present to determine if our programs are able to meet the educational needs of the student. Please contact Cynthia Aguilar, Director Gateway to College, at (915) 831 4700. EPCC accepts students 16 20 from school districts that have contracts with us. We currently have contracts with the districts listed below. Student Name Page 6 of 7
COUNSELOR APPROVAL FORM Entering Semester: FALL SPRING YEAR Date: Student Information Name: Address: Zip Code D.O.B Age: Phone # Alternate Phone # SS# To Be Completed By High School Counselor High School: Transcript o attached o faxed o mailed o other EOC/TAKS Results & Profiles Special program Participation The applicant does not have an IEP or 504. The applicant does have an IEP or 504. The IEP team will meet on the following date to determine if placement into EPCC is appropriate: (Please contact Cynthia Aguilar at (915)831 4700 Approved by: (Counselor Signature) (Counselor Printed Name) Counselor Phone: Fax: Counselor Email: 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. 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. * For additional information call the Gateway to College Office: (915)831 4700, Fax: (915) 831 4702 Mail correspondence to: El Paso Community College, PO Box 20500, El Paso, TX 79998 Student Name Page 7 of 7