Union Settlement College Readiness & PACT Application Form

COLLEGE READINESS & PACT PROGRAM

Please fill out as completely as possible
Date

Month Day Year
Today's Date
Student Information
Student Name *

Last Name First Name Middle Name or Initial
Social Security Number
NYC Department of Education OSIS Number *
Located on your student ID and on report cards
Gender *
Address *

Street Address

Apartment Number

Zip Code
Student E-mail *
example@example.com
Student Mobile Number *
Birth Date *

Month Day Year
Current School *
Current Grade in School *
Ethnic Background *

American Indian/Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian/Pacific Islander White Multiracial Prefer not to say
U.S. Residency Status *

U.S. Citizen Legal Permanent Resident Conditional Resident Prefer not to say
Permanent Residents Only: Please provide A-number/USCIS number
Family / Household Information
Student Lives with: *

Mother & Father Mother only Father only Legal Guardian(s) Other caregiver(s)
If "Other" checked above, please explain
Are You a Ward of the State or in Foster Care?

Yes No
What Is the Total Number of Persons Living in the Household?
What is/are the source(s) of income for the household? (please check all that apply) *

Employment Pension Social Security Public Assistance Other
If "Other," Please Describe
Name of Mother or Legal Guardian 1

First Name Last Name
Occupation of Mother or Legal Guardian 1
Contact Information for Mother or Legal Guardian 1

Cell/Mobile Telephone Number Email Address
Mother or Legal Guardian 1: Did You Graduate from a 4-year College in the U.S.?

Yes No
Name of Father or Legal Guardian 2

First Name Last Name
Occupation of Father or Legal Guardian 2
Contact Information for Father or Legal Guardian 2

Cell/Mobile Telephone Number Email Address
Father or Legal Guardian 2: Did you graduate from a 4-year college in the U.S.?

Yes No
Important: Please Read, Then Sign Below

By signing below, I certify that all the information on this application and any attached documents are true and complete to the best of my knowledge. I give permission for Union Settlement College Readiness Program (USCRP) to obtain full access of my child’s academic records from school or the Department of Education to help my child with both academic and college preparation. I authorize the release of official High School and college records to USCRP. I understand that this information will be used to assess the student’s needs for program services, discern his/her educational progress, evaluate the effectiveness of program activities and fulfill program reporting requirements.
Student Signature

Clear
Parent or Legal Guardian Signature

Clear
College Readiness & PACT Services
Your Areas of Interest (please check all that apply) *

Tutoring / Academic Support / Test Preparation College Prep Workshops College Transition Workshops High School Admissions Test Prep Leadership Development Summer Writing & Theater Program PACT 1st Year Transition Services
Needs Assessment (please check all of the following that apply to you) *

Help with basic mathematics Help with reading at grade level Help deciding on educational goals Help deciding on career goals Help in the form of workshops and/or small group sessions Help finding and connecting with academic support services Help with attendance and/or homework completion Help with developing an academic achievement mindset Help with college financial aid and/or financial planning for college Help with improving your social and/or emotional skills Help preparing and registering for college entrance exams (ACT & SAT) Help with setting achievable goals (academic and/or career) Help with improving your problem-solving and critical thinking skills Help with developing college-ready study skills
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COLLEGE READINESS & PACT PROGRAM

Student Information

Family / Household Information

Important: Please Read, Then Sign Below

College Readiness & PACT Services