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 Contact Information
(in the event we can't reach you regarding your application)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to you.
Date of Birth
-
Month
-
Day
Year
Date
I identify my gender as:
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 AND have access to a car?
Yes
No
If accepted will you have transportation to and from college?
Yes
No
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?
Number of credits completed, if any
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
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 have medical assistance?
Yes
No
Do you have a mental health diagnosis?
Yes
No
What is your current mental health diagnosis?
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
List Other Services you are receiving
Have you ever been hospitalized for mental health treatment?
Yes
No
When was your most recent discharge?
Have you ever received treatment for drug/alcohol use?
Yes
No
If you have received treatment for alcohol and substance abuse, how long have you been in recovery? (In months and/or years)
When was your most recent discharge?
Educational/Career Goals
How did you hear about College Plus?
How long have you been thinking about going to College (or going back to College)?
What Is Your Educational / Career Goal?
In the next 5 years, how do you see your life different than it is now?
Please use the space below to write a short essay: Why do you feel now is the right time in your life to pursue furthering your education?
SUBMIT
Should be Empty: