College Steps Student Application 2

! College Steps Application for Admission 2017-2018 Thank you for your interest in applying to College Steps. Please complete the following application and email all applications materials to [email protected] when finished. Please complete the application in its entirety. Applications are reviewed on an ongoing basis. Please include all relevant prior educational evaluations, psychological evaluations, or any other background information that would help us in getting to know you better. Unless otherwise specified, the application deadline for fall admission is April 1st. Please select the College Steps curriculum to which you are interested in applying (select one only): College Students High School Transition Services* Two year Certificate Program** * High School Transition Services for youth aged 16-21 (not available in all areas) ** Two year Certificate Program for high school graduates up to the age of 26 years, interested in gaining 2 year certificate in higher education (not available in all areas) Do you have a high school diploma Yes* No www.collegesteps.org [email protected] If so, please specify diploma type _____________________ Please specify date of graduation _____________________ *Please include a copy of your diploma in your application materials Please select the College Steps campus to which you are interested in applying (select one only): Northern Virginia Community College (Annandale) Northern Virginia Community College (Loudoun) Norwalk Community College Castleton University Johnson State College Southern Vermont College Lyndon State College Rockland Community College American International College Westchester Community College Please select the semester you are interested in beginning your enrollment: Fall Spring Semester Year ________ Part A STUDENT DEMOGRAPHIC INFORMATION Last name: First Name: Middle: Gender (M, F, other): Date of Birth: Phone number (daytime): Phone number (evening): www.collegesteps.org [email protected] Email address: Mailing address: Parent/Caregiver 1 Last name: First Name: Middle: Relation to applicant: Phone: Email: Parent/Caregiver 2 Last name: First Name: Middle: Relation to applicant: Phone: Email: Applicant lives with: Both parents Guardian Mother Other* Father Shared Living Provider *Explain: www.collegesteps.org [email protected] Part B STUDENT HISTORY In the following section, please provide a brief medical and/or mental health history of the applicant. Case Manager (if applicable) First Name: Last Name: Designated Agency/Community Support Agency: Office Phone: Mobile Phone: Special Education Coordinator (if applicable) First Name: Last Name: School District/Supervisory Union: www.collegesteps.org [email protected] Office Phone: Mobile Phone: **Please include all recent or relevant evaluations (IEP and or exit summary, psychodiagnostic, psychoeducational, etc.) Background Check Other than traffic offenses, have you ever been convicted of any misdemeanor, felony, or other crime? Yes︎ No︎ If you answered yes to either the above question, please provide an explanation and the approximate dates of the incident(s) below. Part C FINANCIAL PLAN Please select one or more of the following descriptors to describe the applicant’s plan to finance the College Steps Program: Special Education Services Medicaid Waiver Private Pay 5 hours per week 15 hours per week 20 hours per week *All final decisions on the number of hours of support per week are made in conjunction with the College Steps admissions team Other, please explain *If applicable, please include a copy of your high school diploma *Please include all recent or relevant evaluations (IEP and or exit summary, psychodiagnostic, psychoeducational, etc.) www.collegesteps.org [email protected] Part D WRITTEN SUMMARY Attached to this application, please include a brief writing sample (1-2 pages) describing: 1. Why do you want to go to college? 2. What are your college goals? 3. How can College Steps help you to achieve your college goals? www.collegesteps.org [email protected] .

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