Fillable Cowley County Community College - IMPACT Program Application

Fill Online, Printable, Fillable, Blank Cowley County Community College - IMPACT Program Application Form

Use Fill to complete blank online COWLEY COUNTY COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Cowley County Community College - IMPACT Program Application

On average this form takes 26 minutes to complete

The Cowley County Community College - IMPACT Program Application form is 4 pages long and contains:

  • 2 signatures
  • 87 check-boxes
  • 55 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Cowley County Community College

BROWSE COWLEY COUNTY COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 











 
  







IMPACTProgramApplication
Student Information
* First Name:
*Dateof Birth:
Month/Date/Year
* Mailing Address:
* State:
* Cell Phone:
*Male Female
*U.S. Citizen PermanentResident
*Student ID#: ‐
* Last Name:
Dorm
Room:
* City:
* Zip Code:
Home Phone:
Refugee
Ethnicity‐PleaseSelectAllThatApply
AmericanIndian/Alaskan Asian
Black/African American Hispanic/Latino
Caucasian/White Hawaiian/PacificIslander
IMPACT/TRiOProgramQuestions
Hasyourmotherreceived/earnedabachelor’sdegree(completed all 4 Year): Yes No
Hasyourfatherreceived/earnedabachelor’sdegree(completed all 4 Year): Yes No
Don’t Know
Don’t Know
Haveyoueverparticipated inanyother TRiOprogramsin middle school,highschoolorcollege?
TalentSearchProgram UpwardBound
EducationalOpportunity Center StudentSupportServices
PriorSchoolInformation
High School Attended: City: State:
Did you graduate: Yes
No If
YES
, date graduated:
If NO, What is your anticipated date:
Did you receive your GED: Yes No N/A If
YES
, date completed:
Didyou take the ACT: Yes No N/A
If
YES
, what was your composite score:








Haveyouattendedanyothercolleges/academies/techschoolsafterhighschool: YesNo
IfyouansweredYEStothepreviousquestion,pleaseprovideadditioninformationbelow:
School Name: Year Started: Year Ended:
StudentorFutureStudentStatus
Full Time(12+ hoursper semester) PartTime (Lessthan12hourspersemester)
CampusPreference
ArkansasCity Mulvane Wellington Wichita Downtown
When was
OR
will be your first semester at Cowley College?
Semester:
Fall Spring
Year:
HaveyoutakenanyCowleyCollegeclassesBEFOREapplying forourprogram? Yes or No
DeclaredorPreferredMajor: (Please Write yourMajor)
Declared Career Choice:
OR
Undecided
Whatisthe highestdegree you would liketoreceive (Pickone):
Associate(2 years) Bachelors(4years)
Masters(4years+ 2 yearsofgradclasses) Doctoral(anythingabovea masters)
Please identify and describe any documented disability you may have:
What services, in the past have you received to accommodate your documented disability:
**Note:DocumentationofyourdisabilitymustbegiventoCowleyIMPACT.Thisinformationis retained in
confidentialfilesandonlyusedbytheIMPACTorADA offices.








CheckalloftheservicethatmayinterestAND/ORbenefityou:
Counseling Transfer Planning
Academic Advising/DegreePlanning CollegeInformation
Financial Aid ApplicationAssistance College Application Assistance
CareerCounseling
Career/Interest Testing
PersonalCounseling
Academic Support/Instruction
Math Tutoring
ReadingTutoring
PeerMentoring
Writing/CompositionTutoring
ComputerApplications
ResumeorInterviewAssistance
Other Classes:
Time Management
CollegeVisit
Scholarship
Workshops
OvercomingTest Anxiety
Note‐taking Tips
HelpGetting Organized
StressManagement
How touseaGraphing Calculator
How to Writean EffectivePaper
MoneyManagement
Whatobstacle(s)wouldmostlikelypreventyoufromcompletingyour academicgoals: (Checkall thatapply)
PoorStudyHabits
LackofMoney
TakingtheWrongClasses
AlwaysFeelingTired
AlwaysWorrying
BeingShy
EasilyDistracted
BadGrades
TakingThings TooSeriously
ProblemsatHome
TroubleSleeping
AfraidtoSpeakUpinClass
FeelingDepressedorSad
DealingwithBillCollectors
FamilyMedicalProblems
SeparationorDivorce
NoFriendsatCowley
Recurring HealthConcerns
Alcoholand/orDrug Issues
NoSupportfromFamily
Friends
AdditionalQuestionsfortheIMPACT/TRiOProgram
**Note:Your abilityto writeand expressyourselfisNOTaconcernfor theapplicationprocess.Youranswerswillbe
usedtodetermine the levelofyourcommitment totheprogramandassistusinprovidingyouwiththehighest levelof
service.
How did you hear about the IMPACT program?
Explain the reason(s) why you are applying for the IMPACT/TRiO program:











Ifyouhadtodescribeyourselfinonlythreewords,whatwould theybe:
1) 2) 3)
** Complete the followingsentence below toidentify yourL o n g ‐ t e r m g o a l s . Thesemay berelatedtobutare not
limited to: school,work,family,livingarrangements,personal healthand/orfinancialsituation
In five years, I want to be:
** Complete the followingsentence below toidentify yourShort‐termgoals. Theseneed to berelatedtoyourlong‐
termgoalsidentifiedinthe lastquestion.What are yougoingtodorightnowsoyoucanachieveyourlong‐termgoals?
Academic Goal(s)‐ Thismayaddressbut is notlimitedtoimproving/maintaining yourcurrentGPA,choosea4‐year
college
and following their degree plan and/or transferring onto a 4‐year College.
Career/WorkGoal(s)‐ This mayaddressbutisnotlimitedtoselectingyourcareergoals,getting a part‐time jobwhile
attending college,helpfindinga new/betterjob, reducing your workhoursto dedicate more timeonschool,helpin
finding
an internship, job shadowing opportunities or help applying for a work‐study job on campus.
* If you plan on working during school, how many hours a week would you work:
Personal/Other Goal(s)‐ Thismayaddressbutis notlimited to improvingfinanciallife, dedicating moretimeto family,
children,spouse,becomingmoreinvolvedin socialactivities,college groups,on‐campusprograms,improving your
spiritual
life and/or attaining other personal milestones.
Student Publicity
Release
I agree thatif I amaccepted intotheIMPACT/TRiO program, the staffmayincludemy nameand/orpicture in
publications,including but isnotlimitedtothe IMPACTwebsites.Thewebsites areused tohighlightstudent
accomplishmentsandparticipationincampusand IMPACT/TRiO activities.
Signature: Date:
Releaseof
Information
IcertifythattheinformationthatIhaveprovidedon thisapplication is,to thebestofmy knowledge,complete and
accurate.Furthermore,Iunderstand thatbyapplyingfor the IMPACT/TRiO program,I authorizethe programstaffto
obtainrecords orpertinentdata thatis necessaryforthisprogram. The program isa federalgrantprogram andsome of
ourrecordsmaybe releasedto the UnitedStatesDepartmentof Educationsor TRiO programs.The IMPACT/TRiO staff
alsohasmy permissiontocommunicate verballyorotherwisewith staff,facultyand/oroff‐campusprofessionalsonmy
behalf.
Signature: Date:
7/2018
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Cowley County Community College - IMPACT Program Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 April 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document