Fillable 2021 Fall Future Focus Application And Intake Forms (Quinsigamond Community College)

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2021 Fall Future Focus Application And Intake Forms (Quinsigamond Community College)

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For any questions, contact Gilmarie: gvongphakdy@qcc.mass.edu or 508-854-2876
Future Focus Eligibility Checklist
Do you have all Four things needed to become a Future Focus Student?
฀ I have a high school diploma (any country) or high school equivalency
a. For HiSET/GED students, you must complete all exams by the start of
the semester (by September or by January)
฀ I qualify for Massachusetts in-state tuition by being either a:
a. Resident of Massachusetts for 6 months or more
AND
b. US citizen, Permanent Resident (Green Card), Legal Asylee, or qualifying
Visa holder
i. Contact the Admissions Department for more information on qualifying Visa -
Ph: 508-854-4262 or Email:
admissions@qcc.mass.edu
฀ I am able to communicate, read, write, and speak English proficiently
฀ I am motivated and committed to doing the following to be a Future Focus
student:
a. Attending college as a part-time student and being present every week
b. Attending monthly workshops
c. Attending monthly advising sessions with the Program Coordinator
Future Focus Application
FALL (SEPT. START) DEADLINE:
JULY 24
TH
SPRING (JAN. START) DEADLINE:
DECEMBER 13
TH
Contact Future Focus Coordinator Gilmarie Vongphakdy with any questions:
Ph: 508-854-2876 or Email: gvongphakdy@qcc.mass.edu
For any questions, contact Gilmarie: gvongphakdy@qcc.mass.edu or 508-854-2876
TO SUBMIT: Please email the Future Focus Application and Intake form,
QCC Admissions Paperwork, Copy of Transcript (and any other
supporting documents needed: please read below), essay, Letters of
Recommendation (optional) to:
E-mail:
gvongphakdy@qcc.mass.edu
You must submit ALL four parts of this application to be considered:
1. Copy of High School Completion Transcript
a. HiSET/GED Students:
i. Complete Transcript with all scores
b. For U.S. High School Students:
i. High School Transcript
c. ESOL Students
i. Copy of a Graded Writing Sample from ESOL classes
ii. Copy of your High School Diploma (from your country)
e help of your teacher/advisor
3. QCC Admissions Paperwork (attached)
4. A typed essay (400-600 words) which answer these two questions:
a. What was a goal you achieved that was particularly significant to you?
i. Why was this goal important and how did you achieve it?
ii. What was the motivation behind this goal?
iii. What was learned from this experience that could be useful in the future?
b. Why do you want to attend college?
i. How are you prepared for college?
ii. Who do you turn to for support?
iii. What area/s are you interested in studying?
5. Optional: One or Two letters of recommendation
a. Must be from an individual who is not your relative and can comment
on your qualifications and motivation to participate in the Future
Focus Program. This can be email directly to Gilmarie by the
recommender at gvongphakdy@qcc.mass.edu.
Once ALL parts have been received, you will be contacted to set up an interview
with Gilmarie, for a final determination on your eligibility for the program.
Please submit all the items together in one email.
required parts of this application to be considered:
QCC Application for Admission
(attached)
Student Intake Form for FY 2022 (attached)
The Future Focus Application Form for FY 2022 (attached)
For any questions, contact Gilmarie: gvongphakdy@qcc.mass.edu or 508-854-2876
(COVID-19 Application Version)
Do you have a computer (laptop/desktop)? YES or NO
(Please check one)
Referring Adult Learning Program Name: __________________________________________
Today’s Date: _________________
Applicant’s Name: _______________________________________________________________
(Last name, First name and Middle name)
Address: _____________________________________ Apt. #: _________
City: ___________________________________ State: __________ Zip Code: ____________
Home Phone: ________- _________- _________ Cell Phone: ________- ________- _________
Email: ___________________________________________________________
Gender: Male ____ Female ____ Social Security Number: ________- ________- _________
Date of Birth: ______________ Location of Birth: ___________________________________
(MM/DD/YEAR) (List city and state if US, List city and Country if outside US)
Race/Ethnicity - Check as many that apply:
Native American or Alaska Native African-American/ Black Caucasian Asian
Native Hawaiian or Other Pacific Islander Hispanic/Latino Other: ________________
Immigrant: Yes No
First Language: _____________________ Language Spoken at Home: _________________
Are you a United States citizen? Yes OR No
If no, which one of the conditions do you meet?
Permanent Resident (Green Card) - Registration Number (USCIS): ___________________
Legal Asylee (Refugee) - Registration Number (USCIS): _____________________________
OR
Please state your Visa or Immigration status: _______________________________________
(Visa issued and Home country
Have you ever attended public education (K-12, ABE, or Comm. College) in Mass.? Yes No
Future Focus Application Form for FY 2022
For any questions, contact Gilmarie: gvongphakdy@qcc.mass.edu or 508-854-2876
(Name of Institution) (Years completed) (Degree- if applicable)
EDUCATION- Check as many that apply
U.S. High School Diploma or GED/HiSET: _______________________________ (Must Provide Copy)
(List your diploma AND include year of completion)
Foreign Country High School Diploma: ___________________________________ (Must Provide Copy)
(List the country AND include year of completion)
College/Technical (in United States): ___________________________________________________
INTAKE FORM- FY 21
COLLEGE CLASS SCHEDULE– MUST CHECK OFF ONE OPTION
(Only applicable for the first semester)
OR
For Office Use- Release of Information Form Signed: Yes No
EMPLOYMENT AND HOUSEHOLD INFORMATION
Employment Status:
Employed Unemployed and Looking for Work
Unemployed and Not Looking for Work Retired or Otherwise Not Looking for Work
Homemaker
Employment Job Type (if applicable):
Full-time (30 hours or more/wk) Part-time (less than 30 hours/wk)
Temporary Jobs Multiple Jobs
Days and Hours at Work:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Start
End
Start
End
Start
End
Start
End
Start
End
Start
End
Start
End
Times
# of hours
What is your Occupation (required if employed)?
________________________________________
Mornings
Tuesdays and Thursdays
FYE 101 – 9:30am- 10:45am
CIS 111 – 11:00am- 12:15pm
Evenings
Tuesdays and Thursdays
FYE 101 – 4pm- 6:50pm (Monday)
CIS 111 – 4pm- 6:50pm (Thursday)
1
Referring ABE Program: _____________________________Today’s Date: _______________
(ABE is the HiSET, ESOL, or Career Pathways Program you attended)
COLLEGE CLASS SCHEDULE– MUST CHECK OFF ONE OPTION
(Only applicable for the first semester)
OR
PERSONAL INFORMATION (MUST BE IN PRINT, NICELY)
Applicant’s Name: __________________________________________________
(Last name, First name and Middle name)
Current Address Homeless: Yes No
Address: _____________________________________ Apt. #: ________
City: ___________________________________ State: __________ Zip Code: ____________
Home Phone: _______________________ Cell Phone: _________________________
Email: _______________________________________
For Office Use- Release of Information Form Signed: Yes No
EMPLOYMENT AND HOUSEHOLD INFORMATION
Employment Status:
Employed Unemployed and Looking for Work
Unemployed and Not Looking for Work Retired or Otherwise Not Looking for Work
Homemaker
Employment Job Type (if applicable):
Full-time (30 hours or more/wk) Part-time (less than 30 hours/wk)
Temporary Jobs Multiple Jobs
Days and Hours at Work:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Start
End
Start
End
Start
End
Start
End
Start
End
Start
End
Start
End
Times
# of hours
What is your Occupation (required if employed):
________________________________________
Mandated Enrollment: Yes No
Mornings
Tuesdays and Thursdays
FYE 101 – 9:30am- 10:45am
CIS 111 – 11:00am- 12:15pm
Evenings
Tuesdays and Thursdays
FYE 101 – 4pm- 6:50pm (Tuesday)
CIS 111 – 4pm- 6:50pm (Thursday)
4pm- 6:50pm (Monday)
Mondays and Thursdays
Student Intake Form for FY 2022
2
Public Assistance: Referred by/Heard About Program From:
Barriers to Education:
Disabilities and Accommodations:
This Adult Basic Education Program does not discriminate on the basis of disabilities.
Students/Applicants may, but do not have to disclose disabilities. Applicants who disclose
disabilities may be entitled to reasonable accommodations.
Please answer Yes or No to the following questions:
1
Does the student/applicant understand that he/she is not required to disclose
his/her disability?
2
Does the student/applicant wish to disclose a disability?
3
Does the student/applicant understand that self-disclosing a disability makes
him/her eligible for reasonable accommodations?
4
If Yes to #3, does the student/applicant wish to request any specific
accommodations?
฀ Emergency Aid to the Elderly, Disabled
and Children (EAEDA)
฀ MassHealth
฀ Supplemental Nutrition Assistance
Program (SNAP)
฀ Supplemental Security Income (SSI)
฀ Transitional Aid to Families with
Dependent Children (TAFDC)
฀ Women, Infants and Children Program
(WIC)
฀ Other: __________________________
฀ None
ABE Program
Career Center
Counselor
Flier/Brochure/Poster
Library
Other
Recruiter
Student (Current/Previous)
Waiting List
Walk-in (school)
Community Organization
Court
Head Start
Job
Literacy Hotline
Probation Officer
Head Start
Unemployment Office
MA Rehabilitation
฀ Displaced Homemaker
฀ Ex Offender
฀ Foster Care Youth
฀ Long Term Unemployed
฀ Low Income
฀ Migrant Farmworker
฀ Seasonal Farmworker
฀ Single Parent or Gaurdian
฀ Other: __________________________
฀ None
Student Intake Form for FY 2022
฀
c
c
c
c
þ
PERSONAL INFORMATION PLEASE PRINT Social Security Number ccc cc cccc
Legal Last Name cccccccccccccccc Legal First Name ccccccccccccccc
Legal Middle Name ccccccccccccccc Maiden Name cccccccccccccccc
Date of Birth cc cc cc Sex: Please check (þ) c Male c Female
(month/day/year)
MAILING ADDRESS
ccccccccccccccccccccccc Preferred Phone ccc ccc cccc
(Box, Apt., or Street Name and Number) (Area Code)
ccccccccccccc cc ccccc
(City) (State) (Zip Code)
E-MAIL ADDRESS
ccccccccccccccccccccccccccccccccccc
PLEASE CHECK WHICH SEMESTER YOU WISH TO ENTER
c Fall (Sept.-Dec.) 20_ c Spring (Jan.-May) 20_20___ c Summer (May-Aug.) 20____
n Have you previously: Please check (þ) c Applied c Attended c Neither c Both
If you have applied or attended, yes, what name did you use during that enrollment? _______________________________________
If you have applied or attended, please indicate in which semester and year _____________________________________________
n Please indicate the Study Option you are applying to: ____________________________________________ cccc
Please write out Study Option above and print the code in boxes at right. See Study Options insert for code.
n Nursing Applicants: Will you be transferring Nursing courses? Please check (þ) c Yes c No
n Will you be attending full-time or part-time? Please check (þ) c Part-time c Full-time
n What is the highest diploma, degree, or certicate you have achieved? Please check (þ) only one of the following:
c High School Diploma c HiSET or High School Equivalency c No H.S. Diploma or HiSET c Homeschool Diploma
c Certicate or Associate’s Degree c Bachelor’s Degree c Graduate Degree
n Are you interested in receiving information about disability services? Please check (þ) c Yes c No
n Have you ever served in the U.S. Military? Please check (þ) c Yes c No
FINANCIAL AID
Quinsigamond Community College awards millions of dollars in federal, state and institutional nancial aid each year to eligible students.
Many students, however, miss out because they do not think they are eligible and do not complete the Free Application for Federal Student
Aid (FAFSA). Financial Aid can be used to pay for tuition, fees, books, transportation and other educational expenses.
We strongly encourage you to complete the FAFSA. If you need help with your nancial aid application or college nancial planning, our
Financial Aid Ofce has counselors who can assist you.
Please select the option below that best describes your plans to complete a FAFSA. This information will have no impact on
whether you are admitted to the college.
c I plan to apply for Federal, State and Institutional Financial Aid and am prepared to complete the FAFSA at www.fafsa.gov.
c I plan to apply for Federal, State and Institutional Financial aid, but I need help from the Financial Aid Ofce to complete the FAFSA.
c I do not plan to apply for Federal, State or Institutional Financial Aid at this time.
GENERAL INFORMATION
What is your educational goal at Quinsigamond Community College? Please check (þ)
c Receive an Associate Degree or Certicate in the program to which you applied.
c Take courses to qualify for another QCC Program of Study: indicate desired program ______________________________
c Take courses for personal or career enrichment.
c Transfer courses to another institution, without receiving a degree.
Quinsigamond Community College, 670 West Boylston Street, Worcester, MA 01606-2092
• 508.854.4262 • fax 508.854.7525
Application for Admission
þ
c
c
c
c
X
X
X
X
X
X
Future Focus ATTN AiCO
General Studies
G S
21
Quinsigamond Community College • www.QCC.edu • email: admissions@qcc.mass.edu
ADDITIONAL INFORMATION
The following information, which is voluntary, will help us to better know our student body and enable us to comply with governmental statistical requests. Responses will not be a
factor in admissions decisions made by the college, but will be made a part of the Permanent Student File, which is protected by Federal and State Privacy Legislation.
n Ethnic and Racial Background
1. Are you Hispanic or Latino?
c Yes c No
2. Please select all that apply: c American Indian/Alaskan Native c Native Hawaiian or other Pacic Islander c Asian
c Black or African American c White c Other________________
3. Please indicate the primary language spoken in your home:________________________________________
n Are you: c Married c Single c Divorced c Widowed
ACADEMIC INFORMATION
High School (from which you will have graduated)
Name
________________________________________________City_______________________State/Country____________
CEEB # (H.S. Code number if known) cccccc Year of Graduation (actual or anticipated) __________
College
Name________________________________________________City_______________________State/Country____________
Major __________________________________________________ Year of Graduation (actual or anticipated) __________
College
Name________________________________________________City_______________________State/Country____________
Major ___________________________________________________ Year of Graduation (actual or anticipated) __________
RESIDENCY INFORMATION
n Are you a United States citizen? c Yes c No If not, please complete the following:
n Are you a Permanent Resident Alien?
c Yes (If yes, list alien registration number: ___________________________) c No
n If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail:________________________
REQUIRED
n If you are a US citizen or Permanent Resident, please check one of the following (A, B, C, or D)
A. c I have been a Massachusetts resident for six (6) continuous months and intend to remain here.
As proof of my intent to remain in Massachusetts, I possess at least 2 of the following documents, which I shall present to the institution upon request.
These documents* are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for my high
school diploma). The institution reserves the right to make any additional inquiries regarding the applicant’s status and to require submission of any
additional documentation it deems necessary. Please check-off those documents you possess as proof of your intent to remain in Massachusetts.
c Valid Driver’s license c Utility bills* c Employment pay stub* c Signed lease or rent receipt*
c Voter registration* c State/Federal tax returns* c Mass. High School Diploma c Military home of record*
c Valid Car registration c Record of parents’ residency for unemancipated person* c Other __________________
B. c I do not live in MA but am eligible to participate in the New England Board of Higher Education’s Regional Student Program.
C. c I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts.
D. c I am NOT a Massachusetts resident as dened in A.
CERTIFICATION
I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall
be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.By applying to the college, I have agreed
to receive phone calls and/or text messages from or on behalf of Quinsigamond Community College regarding their products and
services, at the phone number(s) provided on this form, including my wireless number. I understand that these calls may be generated
using an automated technology.
Applicant Signature: _________________________________________________________________ Date _______________________
Parent/Guardian Signature (Applicant is Under 18 Years Old): _______________________________________ Date _______________________
MARK A
MINIMUM
OF 2:
(Or HiSET)
X
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2021 Fall Future Focus Application And Intake Forms (Quinsigamond Community College)

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Completed 3 February 2021

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