College Plus Application
In accordance with all applicable federal, state, and local anti-discrimination laws, prospective students will receive consideration without regard to color, age, race, handicap, sex or veteran status. All info provided is confidential to the College Plus Initiative.
First Name
*
Last Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Main Contact Phone Number
*
-
Area Code
Phone Number
Main Contact Phone Number Type
Home
Work
Cell
Alternate Phone Number
-
Area Code
Phone Number
Alternate Phone Number Type
Home
Work
Cell
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
How Did You hear About College Plus?
Please Check The Option That Applies To Your Employment Status:
I Am Currently Employed
I Am Currently Un-Employed
I Volunteer
Please Check The Option That Applies To Your Employment Status:
Full-Time
Part-Time
Do You Drive?
Yes
No
Do You Have A Car?
Yes
No
If Accepted Will You Have Transportation To & From College?
Yes
No
If Accepted Will You Have Transportation To & From Our Support Groups?
Yes
No
What Is Your Annual Income?
Please Select
- Select Value -
$0 to $15,000
$15,001 to $25,000
$25,001 to $35,000
$35,001 to $45,000
$45,001 to $60,000
$60,000 or Higher
How Long Have You Been Thinking About Going To College (Or Going Back To College)?
What Is Your Educational / Career Goal?
Educational Background/Status
Do you have a high school diploma or GED?
Diploma
GED
Neither
Year of Graduation or GED Certificate
Have you ever applied to Bucks County Community College?
Yes
No
When did you apply?
Have you ever attended ANY college or trade school?
Yes
No
Where did you apply?
What Years?
My curriculum/major will be
I intend to earn a certificate/license
Yes
No
I intend to earn a 2-year (Associates) degree
Yes
No
I intend on eventually earning a 4 year degree
Yes
No
Number of credits completed, if any
Have you previously received loans or grants?
Yes
No
If you currently have a loan, have you made 6 consecutive monthly payments on it?
Yes
No
Clinic Status/Treatment History
Do you have a mental health diagnosis?
Yes
No
What is your current mental health diagnosis?
Have you ever received mental health services?
Yes
No
Do have medical assistance?
Yes
No
Are you currently receiving mental health services?
Yes
No
Where?
Check all services you are currently receiving
Psychiatrist
Outpatient/Individual therapy
Day program
Residential program
Case management
Prescribed medication
Outpatient/group
Other
D&A
List Other Services you are receiving
If you have received treatment for alcohol and substance abuse, how long have you been in recovery? (In months and/or years)
Have you ever been hospitalized for mental health treatment?
Yes
No
When was your most recent discharge?
Have you ever been hospitalized for drug/alcohol treatment?
Yes
No
When was your most recent discharge?
Looking down the road a ways, how do you see your life different than it is now?
We ask that all students accepted into College Plus agree to share their story about their college experience from time to time. This could include speaking to friends, presentations to provider agency personnel (with College Plus staff), or writing your personal story for the Voice and Vision website. Would you be willing to share your story?
Yes
No
Please explain your answer
Please use the space below to write a detailed essay in which you tell us about yourself. You can include information on: Past employment; hobbies and interests; why you want to attend or return to college, etc. Why you think the College Plus peer-led support groups may be beneficial. What kind of additional support would you want College Plus to provide for you that would help you succeed in college?
SUBMIT
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