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FILLABLE ACCESS Collaborative Program Application For CSH 2

The document is an application form for the ACCESS Collaborative Program aimed at CSH students, collecting personal, academic, and financial information. It includes sections for demographic details, current educational status, intended major, and family information. The applicant must also acknowledge understanding of program expectations and consent to communication with relevant organizations for support.

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lanaylaholt900
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12 views3 pages

FILLABLE ACCESS Collaborative Program Application For CSH 2

The document is an application form for the ACCESS Collaborative Program aimed at CSH students, collecting personal, academic, and financial information. It includes sections for demographic details, current educational status, intended major, and family information. The applicant must also acknowledge understanding of program expectations and consent to communication with relevant organizations for support.

Uploaded by

lanaylaholt900
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Office of Diversity & Inclusion

ACCESS Collaborative Program Application For CSH Students

NAME:
Last First MI

School Attending ___________________________________________________________________________________

Sex: □M □F Student ID No.: Date of Birth:

Home/Permanent Address:

City: State: Zip: Phone:

Email Address: [email protected]


________________________

Phone Number: ________________________________________________________

Marital Status: (check one)

□Divorced □Widowed □Separated □


■ Never Married

Ethnicity: (Check all that apply)

□Asian/Pacific Islander /African American □Black/African American □Hispanic/Latino


□Native American □Other (specify) ______________ □White
Do you have FULL PHYSICAL CUSTODY (living with you) of your child(ren)? □Yes □No
Semester you wish to enter the ACCESS Collaborative Program? □Fall □Spring

Updated 05/03/2019
ACCESS Program App. Pg. 2 NAME___________________________

Is you school a training program, 2 or 4 year institution (please circle)?

What year and semester did you enroll? ________________________________


2022 (Fall Semester)

What is your class rank? (circle one) FR SO JR SR GRAD

Are you a full time? □Yes □No


Total number of years you have been in college: 2 years ___

Current college of enrollment: _____________________________


Columbus State Community College

Intended major: _________________________________________


Studio Art

3.0
Current GPA: ___________________________________________

College/Department Academic Counselor and contact information: _______________________________

Intended semester and year of graduation? ____________________

EFC (Expected Family Contribution) _____________ School Year_____________________

Are you currently employed? □Yes □No


If YES…
What is your occupation?

What is your annual income from employment?

Do you intend to work during the academic year?

What do you anticipate your income to be?

Total number of members in your household? ____________________

For each child, please provide the following information:


(if necessary, please attach additional sheets to include all children)
Full Name Gender Date of Birth School/ Grade

If your child(ren) are not of school age, please provide the Name, Address and Telephone number of your caregiver(s):

1.

Updated 05/03/2019
ACCESS Program App. Pg. 3 NAME___________________________

Please provide the following information for an Emergency Contact:

1.
Name Address Phone # Relationship

Are you receiving any of the following: (Check all that apply)

□Title XX □Food Stamps □Healthy Start or Medicaid


□Cash Assistance □WIC □Other (specify) ____________________________

*My signature below indicates that I fully understand the following:


1. If admitted to the ACCESS Collaborative Program, I’m expected to sign and abide by all
terms in the agreement that governs the Program.

2. The ACCESS Collaborative Program staff will make every effort to assist me in my academic
and personal growth. In doing so, they may need to speak with a community organization
and/or person(s) who may assist me with my situation. I give the ACCESS Collaborative
Program staff permission to discuss my situation with appropriate organizations and/or
persons to advocate for me on my behalf.

3. I will participate in all recommended (if necessary) interventions that will assist in my
academic and personal growth.

4. All services provided by the ACCESS Collaborative Program are subject to change without
notice.

Signature* Date

Updated 05/03/2019

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