College Steps Application for Admission

Student Information

BACKGROUND INFORMATION
Application Type
Student Name

First NameLast Name
Preferred Name
Preferred Student Name
Gender
Preferred Pronouns
Date of Birth

MonthDayYear
Student Email
example@example.com
Student Phone Number
Format: 000-000-0000. Provide student number only.Format: 000-000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState (Format: VT)/ Province

Zip CodeCountry
How did you initially learn out about College Steps?
Additional Details
Include Event/Date, online web search, Contact, etc.
Consent to Communicate

Information on Parent(s)/Caregiver(s)

May include other contact for independent students
I Need to Update my Guardianship or Family Contact Information
Guardianship

Other
Additional Guardianship Information
Please Include a Parent/Caregiver in our Followup
Applicant lives with:
Explain Other
Parent/Caregiver 1

First NameLast Name
Relationship to Applicant
Parent/Caregiver Email
example@example.com
Parent/Caregiver Phone Number
Format: 000-000-0000Format: 000-000-0000.
Parent/Caregiver 2

First NameLast Name
Relationship to Applicant
Parent/Caregiver 2 Email
example@example.com
Parent/Caregiver 2 Phone Number
Format: 000-000-0000Format: 000-000-0000.

Part C

EDUCATIONAL BACKGROUND
I Need to Update my Educational Background Information
High School Status

Other
Please specify diploma type:
Date of High School Graduation or Anticipated Completion

MonthDayYear
School District
High School
High School Location (City, State):
District Contact

First NameLast Name
District Contact Email
example@example.com
District Contact Phone Number
Format: 000-000-0000Format: 000-000-0000.
Additional District Team Members
If you currently or previously require(d) support from a PCA or one-on-one Paraprofessional, please describe the support you receive(d):

Part D

STUDENT HISTORY
Please provide your social or learning challenge diagnosis:
Have you discontinued a program prior to completion?
If yes, explain:
Have you had any prior psychiatric hospitalizations?
If yes, additional documentation will be requested.
Background Check: Other than traffic offenses, have you ever been convicted of any misdemeanor, felony, or other crime?
Additional Details
I work with an Educational Advocate or Attorney
Educational Advocate/Attorney

First NameLast Name
Educational Advocate/Attorney Email
example@example.com
Educational Advocate/Attorney Phone Number
Format: 000-000-0000Format: 000-000-0000.
I am supported by a State or Community Agency
Designated Agency/Community Support Agency
Case Manager/Coordinator

First NameLast Name
Case Manager/Coordinator Email
example@example.com
Case Manager/Coordinator Phone
Format: 000-000-0000Format: 000-000-0000.
I have an additional case managers to include
Designated Agency/Community Support Agency
Case Manager/Coordinator

First NameLast Name
Case Manager/Coordinator Email
example@example.com
Case Manager/Coordinator Phone
Format: 000-000-0000Format: 000-000-0000.

Part E

STUDENT GOALS
The submissions below are used to assist during the student's independent portion of the interview.

They must be written and submitted in the student's own words.
1. Why do you want to go to college?
2. What are your college goals?
3. How can College Steps help you to achieve your college goals?
I confirm the above short answers were written in the student's own words. Note: inaccurate confirmation may result in the withdrawal of the student's application.

File Upload

Cancelof
Part F

SUPPORTING DOCUMENTATION AND APPLICATION SUBMISSION
I Have Updated Documentation to Submit
You will receive a follow up email with a link to upload all relevant PDF Documentation including, but not limited to:

» IEP and/or 504 » Transcripts » Evaluations to include any documentation to support prior treatments or diagnoses (e.g. Psychoeducational, Psychodiagnostic, Speech and Language, Behavior Plans, etc.)
All information submitted above is accurate and no information has been withheld. I understand that any violations to these terms may result in dismissal.
Admissions
Group
Type
Should be Empty:

Student Information