CU-ASPIRE FRESH START PROGRAM

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.

APPLICATIONS WILL BE ACCEPTED UNTIL ALL SLOTS ARE FILLED.

ELIGIBILITY CRITERIA to qualify for the CU-ASPIRE Fresh Start Program:
(1) Eligible applicants will be from any of the 55 West Virginia counties and Allegheny, Washington, Greene, and Fayette Counties (Pennsylvania State) AND

(2) Enrolled Full-time Freshman at Concord University AND

(3) a member of an underrepresented minority group AND/OR income eligible AND/OR first-generation.

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)

II. EDUCATION INFORMATION

High School Name:

High School Address:

SAT - Evidence-Based Reading and Writing Score:

SAT - Math Score

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

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

CU-ASPIRE FRESH START PROGRAM - INTEREST FORM