DRS - Interest Form

Statement of Confidentiality: The information submitted in this form is to determine the applicant’s eligibility for CU-ASPIRE Fresh Start Program. Information received is confidential.

Open to all 55 WV counties. Applications will be accepted until all slots are filled. Registration due date is June 28^th. ONLY 15 SLOTS AVAILABLE.

I. APPLICANT INFORMATION

First Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Email Address

Cell Phone #

Home Phone #

Date of Birth:

Gender:

F

M

Other

Citizenship:

US Citizen

Permanent resident

Other

Parent/Guardian Name:

Parent/Guardian address:

Parent/Guardian phone:

Parent/Guardian email address:

Ethnic Heritage (Please check all that you identify with.)

Other (please specify)

Name of DRS counselor you work with

DRS counselor phone number

DRS counselor email address

II. EDUCATION INFORMATION

High School Name:

High School Address:

High School Grade Level

SAT - Evidence-Based Reading and Writing Score:

SAT - Math Score

Please choose a track

Math

English

Career Interest:

III. FAMILY INFORMATION

Financial information

PELL GRANT eligible?

Financial information

PELL GRANT eligible?

Yes

No

I'm not sure

First Generation

Natural or Adoptive Mother’s Name:

Her Highest Grade Completed

Degree Earned, if any:

Associate’s (2 year)

Bachelor’s (4 year)

Master’s

Doctorate

Natural or Adoptive Father’s Name:

His Highest Grade Completed

Degree Earned, if any:

Associate’s (2 year)

Bachelor’s (4 year)

Master’s

Doctorate

Legal Guardian's Name (if you don't reside/live with a parent):

His/Her Highest Grade Completed

Degree Earned, if any:

Associate’s (2 year)

Bachelor’s (4 year)

Master’s

Doctorate

IV. SPECIAL ACCOMMODATIONS

Is there anything you would like to share with us? Concord will try to make accommodations to the best of our abilities.

Concord University will NOT provide transportation to and from the campus for the participants. Please contact your CRP or DRS counselor in regard to transportation from home to the campus and from campus to home.

Please note: You will be receiving a package that will contain a Summer Camp Handbook along with a Medical Form that will need to be completed and returned to us before the program starts.

YES! I am interested in the program, please contact me.

How would you like us to contact you?

E-mail

Phone

E-mail address:

What time of the day will be best?

Morning

Afternoon

Evening