Student Intake Form

Student Intake Form
- Please note: Students interested in learning more about external fellowships in general are encouraged to review the NCA website (uc.edu/nca) to learn more about the resources and services we offer. - You can book an advising appointment with Dr. Jenny Hyest, NCA Director, via My Bearcat Network. Prior to your advising appointment, please review the Core and Priority Awards listed on the NCA website. *Denotes required question
First Name *
Last Name *
Personal Gender Pronouns:
Name
UC Email *
example@example.com
Secondary Email
(Please list a non-UC email address.)
Phone Number

Area CodePhone Number
Race/Ethnicity (Check all that apply)

American Indian or Alaskan NativeAsian or Asian AmericanBlack or African AmericanHispanic/Latina/Latino/LatinxMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderWhitePrefer not to sayAnother option not listed here (describe below)Other
Are you of Hispanic, Latina/o/x, or of Spanish origin? (Check all that apply)

No, not of Hispanic, Latina/o/x, or Spanish originYes, Mexican, Mexican American, Chicano/a/xYes, Puerto RicanYes, CubanYes, Another Hispanic, Latina/o/x or Spanish originSome other race, ethnicity, or originPrefer to self-describePrefer not to sayOther
Are you inquiring about specific scholarships? If so,which one(s)?

Boren AwardsCritical Language ScholarshipForeign Affairs IT FellowshipFulbright U.S. Student ProgramFulbright UK Summer InstitutesGaither Junior Fellows ProgramGates CambridgeGoldwaterHumanity in Action FellowshipJapan Exchange and Teaching (JET) ProgramKnight-HennessyLuce Scholars ProgramMarshallMitchellNSF GRFPPublic Policy and International Affairs Junior Summer Institute (PPIA)QUAD FellowshipRhodesSamvid ScholarsSchwarzmanPaul & Daisy Soros Fellowship for New AmericansTrumanUdallNo Specific FellowshipOther
Current Student Level *
Major 1 *
Major 2
Major 3
Minor 1
Minor 2
Minor 3
College *
Expected Graduation Date*
(Spring 2021, Summer 2022, etc.)
Expected Graduation Date *

MonthDayYear
Date
Current Cumulative GPA *
M-number *
Have you attended an Intro to Fellowships session? *
Are you in a 4+1 program?
Are you a member of any campus honors programs?
If yes, please list programs.
Are you Pell Grant eligible?
Citizenship *
Have you studied abroad? *
If yes: where, when, and how long?
What languages (other than English) do you speak/study? *
Are you a first-generation college student?

YesNoNot sure
Are you a first-generation American?

YesNoNot sure
What is the highest level of education you aspire to complete? (mark all that apply) *

Bachelor'sMaster'sMSNMPHMPPMSWMBAJDMDDDSMd/PhDEdDPhDOther
Briefly describe your academic and/or career goals. *
Describe up to five of your most meaningful non-class activities (extra-curriculars, community or campus service, jobs, research,co-ops, etc.) *
Please list any scholarships (UC or external) that you have received, as well as any awards or recognitions.
What else do you think we should know about you?
How did you hear about NCA?*
Please list the name(s) of the faculty/staff/student who referred you.
Please upload a professional photo of yourself for our records. *

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Do you need someone from NCA to reach out to you with directions for scheduling an appointment?*

YesNo
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