Personal Information |
| Note: You may need to provide your Social Security Number and/or BPCC ID Number in order to finalize this application. |
| * Full Name: |
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| BPCC ID Number: |
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| * Address Line 1: |
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| Address Line 2: |
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| * City: |
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| * State: |
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| * Zip: |
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| * Preferred Telephone: |
(include area code) |
| Alternate Telephone Number: |
(include area code) |
| * Preferred Email: |
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| * Date of Birth: |
(mm/dd/yyyy) |
| * Place of Birth: |
(City/State) |
| * Gender: |
Male Female |
* Ethnicity:
Are you Hispanic or Latino? |
Yes No |
| * Race (Please select one): |
American Indian or Alaska Native
Asian
Black or African American
White
Native Hawaiian or Other Pacific Islander
Non-Resident Alien |
| * English Language Status (Please select one): |
Native English Speaker
Bilingual (proficient in first language and English)
Limited English proficient
Non-English Speaker |
| * Military Status (Please select one): |
Active Military Duty
Veteran
Eligible family member
Not a Veteran |
| * Are you receiving government assistance? |
Yes No |
| If yes please check all that apply: |
Loan(s)
Pell Grant
Scholarship(s)
Vocational Rehab.
Other (list below)
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| If "Other", please list: |
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| Do you owe any money on Pell Grant, student loans, to any college? |
Yes No |
| If yes, please explain: |
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Employment |
| * Are you employed? |
Yes No |
| * Current or last employer: |
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| * Are you receiving unemployment compensation? |
Yes No |
Education |
| * Last High School Grade Attended: |
9 10 11 12 |
| * Did you graduate? |
Yes No GED |
| * Year of Graduation/GED Year: |
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| College(s) Attended: |
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| In what areas can this program help? (Please check all that apply) |
Academic Advising
Course Selection
Personal Counseling
Computer Usage
Academic Assessment
Financial Aid Advising
Selecting a Major
Study Skills Development
Stress Management
Assistance with FAFSA
Library Research
Scholarship Research
Career Planning
Mentoring
Understanding Degree Requirement
Understanding College Environment
Other |
Other Information |
| * Have you ever been arrested? |
Yes No |
| If yes, please list offense and year: |
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| * Have you ever been convicted a felony? |
Yes No |
| If yes, please list offense and year: |
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Program of Study |
| My career and academic goals include (please check all that apply): |
Career Pathway from Accelerating Opportunities
Work in Cyber Security/Networking
Work in Health Informatics
Work in Industrial Technology
Work in Digital Gaming
Pursue further education (Associate’s, Bachelor’s, Master’s, Doctorate degree) |
Referral |
| Referral Method: |
Radio Flyer Other |
| Referring person/organization: |
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Additional Information/Academics and You |
| In your own words, why do you want to go to college? List some goals. |
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| Have you experienced Test Anxiety that is severe enough to negatively impact your overall grade in a course? |
Yes No |
| If yes, can you please describe the feeling (what happened) during test taking? |
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| Do you have difficulty staying focused while studying for a test? |
Yes No |
| How many hours per week do you plan to devote to studying for your class? |
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| My academic strengths include (please check all that applies to you): |
Ability to read and understand key points in course textbooks.
Ability to critically think and to correctly answer questions.
Ability to take effective notes in class. |
List any additional academic strengths: |
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| My academic needs include (please check all that apply to you): |
Writing Skills
Listening Skills
Test Taking Skills
Computer Skills
Math Skills
Communication Skills
Memorization
Time Management
Reading Skills
Concentration
Typing Skills
Note-Taking |
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| * Enter word shown below: |
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| * Required Fields |
