Rising STARS: Summer Bridge Program Application

Rising STARS: Summer Bridge Program Application
Name*

First NameLast Name
Student ID Number*
Please enter your Student ID Number.
Gender*
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnic Origin

African AmericanAsianCaucasianHispanic/Latin AmericanNative AmericanOther
T-Shirt Size*
High School Education
Name of High School Attended*
Year Graduated*

MonthDayYear
Date
Ranking in Graduation Class*
Most Recent GPA*
Please list all clubs and organizations you were a member of and the position(s) held.*
Please provide any academic achievements or awards you have received in high school (if there are any)*
Overall placement score (ACT, SAT, Accuplacer).*

Information Release
The South Arkansas College Rising STARS Summer Bridge Program has my permission to use my or my child’s photograph publicly to promote the South Arkansas College summer bridge program. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
Student Signature*

Clear

I certify that the information I have provided above are true to the best of my knowledge without any malice or any intention to commit acts of misrepresentation.
Applicant's Signature*

Clear
Date Signed by Applicant

MonthDayYear
Date
Should be Empty:

Rising STAR Student Expectations