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 Inspire. 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 Code Phone Number
Race/Ethnicity (Check all that apply)

American Indian or Alaskan Native Asian or Asian American Black or African American Hispanic/Latina/Latino/Latinx Middle Eastern or North African Native Hawaiian or Other Pacific Islander White Prefer not to say Another option not listed here (describe below)
Are you of Hispanic, Latina/o/x, or of Spanish origin? (Check all that apply)

No, not of Hispanic, Latina/o/x, or Spanish origin Yes, Mexican, Mexican American, Chicano/a/x Yes, Puerto Rican Yes, Cuban Yes, Another Hispanic, Latina/o/x or Spanish origin Some other race, ethnicity, or origin Prefer to self-describe Prefer not to say
Are you inquiring about specific scholarships? If so,which one(s)?

Boren Awards Critical Language Scholarship Fulbright U.S. Student Program Fulbright UK Summer Institutes Gaither Junior Fellows Program Gates Cambridge Goldwater Knight-Hennessy Marshall Mitchell NSF GRFP Rhodes Schwarzman Paul & Daisy Soros Fellowship for New Americans Truman Udall No Specific Fellowship
Have you attended an Intro to Fellowships session? *
M-number *
Major 1 *
Major 2
Major 3
Minor 1
Minor 2
Minor 3
College *
Are you in a 4+1 program?
Expected Graduation Date *
(Spring 2021, Summer 2022, etc.)
Expected Graduation Date *

Month Day Year
Date
Current Student Level *
Current Cumulative GPA *
Are you a member of any campus honors programs?
If yes, please list programs.
Are you Pell Grant eligible?
Citizenship *
Are you a first-generation college student?

Yes No Not sure
Are you a first-generation American?

Yes No Not sure
What is the highest level of education you aspire to complete? (mark all that apply) *

Bachelor's Master's MSN MPH MPP MSW MBA JD MD DDS Md/PhD EdD PhD Other
Have you studied abroad? *
If yes: where, when, and how long?
What languages (other than English) do you speak/study? *
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? *

Yes No
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