The City College of New York

The City College of New York

Urban Scholars College Preparatory Program
2021-22 Scholar Application
Current freshmen or sophomores with a minimum cumulative GPA of 80 or higher are eligible to apply to the Urban Scholars Program. The Urban Scholars Program is designed to provide participants interested in going to college with the academic support and social enrichment necessary for success. To apply, complete and submit the following application along with the required supporting documents to the address listed below.

Completed applications must include the following:

Completed recommendation form from a teacher, and your high school principal or guidance counselor

300 word essay Copy of student’s most recent high school report card and transcript Either one of the following:

Copy of parent/guardian’s most recent Federal Income Tax Return (only the first two pages of 1040)

A Social Services Budget Worksheet (obtained from a case worker) An official letter stating benefits received from Social Security, Alimony, Child Support, etc.

If you have questions or need additional information, please contact the program office at:
URBAN SCHOLARS
Convent Avenue at 138 Street New York, NY 10031 (212) 650-5181 www.urbanscholarsny.org Email: mail@urbanscholars@ccny.cuny.edu

**Please note that if accepted, students and their parents will be required to complete other mandatory forms.
College Preparatory Program
160 Convent Avenue, R5/143, New York NY 10031 Tel: 212 650-6219 /Fax: 212 650-5197
Please fill in all items below. Indicate NA if an item is not applicable.

STUDENT INFORMATION – Please print neatly in ink
Legal Name
Home Address
Apt.
City
State
Home Phone

Country CodeArea CodePhone Number
Student’s Cell Phone

Country CodeArea CodePhone Number
Date of Birth

MonthDayYear
Date
Gender

FM
Social Security No
E-mail
example@example.com
Ethnic Origin

Black, African-American, African DescentNative American, Tribal Affiliation:Hispanic/LatinoAsian/Pacific IslanderWhite (non-Hispanic)Other
Are you a U.S citizen?
If No, please print country of citizenship?
Temporary U.S Resident A#
High School Name

A. Philip RandolphEagle AcademyFrederick Douglass AcademyThurgood Marshall AcademyUrban Assembly School for Global CommerceUrban Assembly for Performing Arts
Current Grade
Borough
Expected Graduation Year
Class Avg.
School ID Number
Please list all NYS Regents level courses (previously taken)

Student Information (continued)

	List any subject/course you have gained lower than 70 avg. in high school:	-	-

Student Information (continued)

	List the courses in which you are weak in and need help.	-	-

Student Information (continued)
List any subject/course you have gained lower than 70 avg. in high school:
What do you plan to do when you get out of high school?

Do not knowJoin the militaryGo to CollegeGet a jobGo to Trade schoolOther

What Careers are you considering?

	List extracurricular activities in which you participate at school (or, outside of school):	-	-

List extracurricular activities in which you participate at school (or, outside of school):
Are you presently employed?

YesNo If yes, list employer:
No If yes, list employer
Type of Job
Days you generally work: [S] [M] [T] [W] [TH] [F] [S] # hrs/week
Days you generally work: [S] [M] [T] [W] [TH] [F] [S] # hrs/week
Days you generally work: [S] [M] [T] [W] [TH] [F] [S] # hrs/week
Days you generally work: [S] [M] [T] [W] [TH] [F] [S] # hrs/week
Days you generally work: [S] [M] [T] [W] [TH] [F] [S] # hrs/week
Days you generally work: [S] [M] [T] [W] [TH] [F] [S] # hrs/week
Days you generally work: [S] [M] [T] [W] [TH] [F] [S] # hrs/week
Days you generally work: [S] [M] [T] [W] [TH] [F] [S] # hrs/week
Which of the following areas do you feel are your strengths? (Check all that apply)

Reading SkillsSelf ConfidenceMath SkillsWriting SkillsCultural AwarenessVerbal SkillsPhysical ScienceNatural SciencesStudy SkillsSelf MotivatedCareer AwarenessOther
In which of the following areas do you feel you need improvement? (Check all that apply)

Reading SkillsMath SkillsWriting SkillsSocial ScienceCultural EnrichmentVerbal SkillsPhysical ScienceNatural SciencesStudy SkillsPersonal SupportCareer AwarenessSelf Image ImprovementInterpersonal SkillsOther
T-shirt size for Program Activities (50/50 cotton):

SMLXL2XL
DO NOT WRITE BELOW THIS LINE - FOR OFFICE USE ONLY
Reviewer Initials
Urban Scholars Application 2021-22
College Preparatory Program
Essay
Applicant Name
Please write an essay on the topic assigned below and respond in detail with no less than 300 words.
Topic: If you had the power to change three things in your community or in the world, what would you change and why?
Family Information
To be completed by the Parent/Guardian with whom the applicant resides:

Female Head of Household


Full Name:
Phone Number:
Email Address

Full Name:

	Female Head of Household Information	-	-
Cell Phone #:
Work Phone #:

Full Name
Occupation
Occupation
Other than applicant, please list all children living in the home:

	Full Name	Age	Grade	Relationship to applicant
1
3
4

Male head of household’s highest educational level

Less than HSGEDHS Diploma
Male head of household’s highest educational level:

Associate’s DegreeBachelor’s DegreeMaster’s DegreeDoctorial Degree
If male of household holds a degree, from what college?
Female head of household’s highest educational level

Less than HSGEDHS Diploma
Female head of household’s highest educational level:

Associate’s DegreeBachelor’s DegreeMaster’s DegreeDoctorial Degree
If female head of household holds a degree, from what college?
Financial Information
You must attach a copy of your latest FEDERAL tax return (1040, 1040A, or 1040EZ) before this application will be considered. Do not include schedules, worksheets or a NEW York State return. If there are two parents/guardians living in the home, then BOTH are required to sign this form.
Family’s TAXABLE (Not adjusted gross) income for the year 2020 is
Family’s Non-taxable benefits ( all that apply)

Social SecurityVA BenefitsTANF/AFDC
Family’s Non-taxable benefits ( all that apply):

Food StampsMedicare/MedicaidChild SupportOther (specify):Other
Family’s Non-taxable benefits ( all that apply)

We/I certify that we/I did not file a federal income tax return(s) for the year 2020.
By signing below, we/I certify that all of the information given in this application packet is true and correct to the best of our/my knowledge.
By signing below, we/I certify that all of the information given in this application packet is true and correct to the best of our/my knowledge.
By signing below, we/I certify that all of the information given in this application packet is true and correct to the best of our/my knowledge.
The Family Educational Rights and Privacy Act (FERPA), Protection of Pupil Rights Amendment (PPRA), 20 U.S.C. §1232g, are established within the federal law to provides for and govern the review and disclosure of student educational information and records. The City College of New York and its Education Enrichment Programs-TRIO and NYSED LPP/ESDVP will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student and parent, except as authorized by FERPA and PPRA.
Male Parent’s/Guardian’s Signature

Female Parent’s/Guardian’s Signature

Student Information Authorization & Release Form

	Student Information
Name (Last, First)
Address (Street, City, State, Zip)
Email Address
Student's Social Security Number
Student School ID Number
Phone Number

In accordance with the Family Education Rights and Privacy Act (FERPA)

I Type a label here by consent to the release of my personal identifiable information specified below to the City College of New York Urban Scholars Program/Upward Bound Program. This consent shall remain in effect through my entire enrolment in high school and postsecondary institutions. I also consent to the City College of New York Urban Scholars Program/Upward Bound Program to track my education persistence through my identifiable information for 7 years after the date of my high school graduation.
Identifiable Information
Grades/GPA, registration, academic performance/standing, class schedule, transcripts and/or enrollment information
Certification

By signing below, I consent to the release of the personally identifiable student information specified above to the entity listed above.
Student Signature

Clear
Release of School Records

	Student Information
Name (Last, First)
Address (Street, City, State, Zip)
Email Address
Student's Social Security Number
Student School OSIS Number
Phone Number

Parental Permission

As the parent and/or legal guardian of the student listed above, I hereby authorize the City College of New York Urban Scholars Program/Upward Bound Program, in accordance with the Family Education Rights and Privacy Act of 1974 and New York State Law, permission to obtain/review copies of my child named above academic grade reports, transcripts, and/or standardized test scores from the school to assist my son/daughter in achieving his/her educational goals, I also grant the US staff my permission to speak with teachers, counselors and other school administrators at my child's school in order to obtain and exchange information as part of the services provided by US Program.

	Parent/Guardian Information
Name (Last, First)
Address (Street, City, State, Zip)
Email Address
Phone Number

Certification

By signing below, I consent to the release of all academic grade reports, transcripts, and/or standardized test scores pertaining to my son/daughter from all education institutions.
Parent Signature

Clear
Should be Empty:

The City College of New York

2021-22 Scholar Application

URBAN SCHOLARS

College Preparatory Program

DO NOT WRITE BELOW THIS LINE - FOR OFFICE USE ONLY

Reviewer Initials

College Preparatory Program

Essay

Family Information

Financial Information

Identifiable Information

Certification

Release of School Records

Parental Permission

Certification