MAP
Male Achievement Program Application
Individual Information
Name
First Name
Last Name
MHU Email
example@example.com
MHU Student ID Number
Birth Date
-
Month
-
Day
Year
Date
Cell Phone Number
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Male Achievement Program Application
Distinctive Information
What year on campus are you?
First Year
Sophomore
Junior
Senior
Are you an athlete? If so which sport?
Enter N/A if not affiliated
List ALL activities in which you participate other than school/classes (Campus Employment, Bonner, etc.)
Residence Hall
Academic Advisor
Major
Name of Highschool
Year graduated from Highschool?
Transfer Student?
Yes
No
Where are you transferring from?
Race
White
Black or African American
Asian
Native Hawaiian or Pacific Islander
American Indian or Alaskan Native
Race
Hispanic or Latino
Non-Hispanic or Latino
Resident Status
US Citizen
Eligible Non-Citizen
No, I am not a citizen or eligible non-citizen
Name of Parent/Guardian 1
First Name
Last Name
Name of Parent/Guardian 2 (If Applicable)
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Male Achievement Program Application
Eligibility Information
Are you:
Dependent
Independent
Unsure?
Do you receive Federal Financial Aid?
Yes
No
With whom have you lived with during the past year? (Who can claim you on their income tax records?)
Father
Mother
Father AND Mother
Grandparent(s)
Other Guardian
Spouse
I am self supporting
Has your mother GRADUATED from a 4-year college?
Yes
No
Has your father GRADUATED from a 4-year college?
Yes
No
If guardian is not a parent, did they graduate from a 4-year college?
Yes
No
N/A
Do you have learning or sensory impairments, ADHD, mobility issues, or any other condition for which you plan to request classroom, scheduling, housing or other accommodations?
Yes
No
Prefer Not To Disclose
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Male Achievement Program Application
Agreement
How did you hear about the Male Achievement Program?
Students
Faculty/Staff/Coach
Brochure
Other
Upon becoming a member of the Male Achievement Program do you consent to using your name image likeness to be used for the program or university's advertising and promotions?
Yes
No
I agree that the Male Achievement Program office may access any of my records stored at the University for determining my program eligibility and/or for advertising. I further agree that the information provided is true and accurate to the best of my knowledge. I hereby give my permission to the MAP staff to release pertinent information in my file to faculty members or professional staff within the university if the MAP office determines that doing so is in my best personal and/or academic interest.
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