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
*
Please Select
Male
Female
N/A
Address
*
Street Address
Apartment Number
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
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Connecticut
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District of Columbia
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Louisiana
Maine
Maryland
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Montana
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Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Student E-mail
*
example@example.com
Student Mobile Number
*
Birth Date
*
Please select a month
January
February
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Month
Please select a day
1
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Day
Please select a year
2024
2023
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Current School
*
Please Select
Esperanza Prep Middle School M372
Harlem Prep Middle School
Joseph Lanzetta Middle School M096
Renaissance School of the Arts
Samuel Stern Middle School M007
Democracy Prep Harlem Charter High School
Esperanza Prep High School
The Heritage School
Innovation Charter High School
Talent Unlimited High School
Current Grade in School
*
Please Select
6
7
8
9
10
11
12
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
Parent or Legal Guardian Signature
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
Is there anything you'd like us to know before you submit this form?
Submit Application
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