Fillable MESA Application And Student Contract 2015-10-06 1 Application Academic Year 2000/01

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MESA Application And Student Contract 2015-10-06 1 Application Academic Year 2000/01

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Country of origin: US
File type: PDF

U.S.A. forms for Mission College

BROWSE MISSION COLLEGE FORMS

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Revised: 2015-10-06
Mission College, MESA Community College Program (MCCP) Application
PLEASE COMPLETE ALL ITEMS AND PRINT CLEARLY
Last 4 #’s of SSN: xxx-xx- Campus student ID: ______________________________
First Name: ________________________________ Middle (or initial): _____________ Last Name: ____________________________________
Permanent Address: ______________________________________________________________________________________________________
Current Address/Mailing Address (if different): _______________________________________________________________________________
City: ___________________________________________________________ State: __________________ Zip: _____________________
Home Phone: ( ) __________________ Work Phone: ( ) _____________________ Cell Phone: ( ) ______________________
E-mail: ______________________________________________________ Birth date: ____/____/____ Gender: Male Female
Ethnicity: (1)_____________________ (2) _____________________ American Indian/Alaskan Native tribal affiliation: ___________________
Is a language other than English spoken regularly in your home? No Yes If yes, specify: ______________________________________
Residential status:
US Citizen
Permanent Resident
F1 Visa
Resident Alien
AB540 or AB2000
When did you first enroll at this college:
_________/_________
Semester Year
Current College Counselor:
______________________________
Total number of college units completed:
0-29 30-60 60+
Do you have a Bachelor’s degree?
Yes No
Current college GPA: ________________
Declared Major: _____________________
What was your first college math class?
Highest level of education achieved by each of your
parents/guardians (please indicate by using a letter):
_______Father _______Mother
A. No school/elementary school
B. 8
th
grade or less
C. Some high school
D. High School graduate
E. Some college/university
F. Community college degree
G. 4-year college degree
H. Professional degree (law, medical, etc)
I. MS/MA/MBA/Ph.D.
J. Other _________________________
K. Don’t know
Current science and math classes:
_________________ __________________
_________________ __________________
Completed science and math classes
(any college):
_________________ __________________
_________________ __________________
_________________ __________________
_________________ __________________
Intended Transfer College(s) – in order of
preference:
1. ________________________________
2. ________________________________
3. ________________________________
Prospective date of transfer:
______/______
Semester Year
Previous school(s) attended:
High School:_________________________
Date: ___________________________
College: ____________________________
Dates: __________________________
College: ____________________________
Dates: __________________________
Obstacles that may interfere with your
education (check all that apply):
Financial need
Employment issues
Family obligations
Knowledge of educational system
Exceptional needs (specify below)
______________________________
Are you employed? Yes No
If yes, how many hours per week? _______
Are you a Veteran? Yes No
Type of work your parents or guardian have done over the past years or
prior to retiring (please indicate by using a letter):
_______Father _______Mother
A. Never Employed
B. Farm Worker
C. Business Administration
D. Retail/Sales/Clerical
E. Mechanic
F. Professional – (Doctor, Lawyer, Other Professional)
G. Factory Worker
H. General Laborer
I. Teacher/Professor
J. Skilled technician – Medical, Educational, Trades
K. Engineer/Computer Scientist/Scientist
L. Other ________________________
M. Don’t know
Revised: 2015-10-06
Are you eligible for Financial Aid? ____ YES ____ NO
First semester and year of college? _________________________ First semester and year at Mission College? __________________________
First college math placement (circle one): Pre-Algebra. (900, 902, 903) / Int. Algebra (C) / Trig (D) / Pre-Calculus (1) / Calculus
First college ESL/English placement (circle one): ESL / Remedial English (905/908) / College English (1A)
How did you learn about MESA? ________________________Are you in other programs on campus (please list):______________________
Are you involved in any student clubs or organizations on or off-campus? If yes, please list: _____________________________________________
Would you like to join a club, if so, please list/describe: _________________________________________________________________________
Do you work? If so please list employer and job title: ___________________________________________________________________________
Your career goal/dream is: _________________________________________________________________________________________________
Your educational goal/dream is: _____________________________________________________________________________________________
MESA STUDENT CONTRACT
We value our students and we want you to enjoy college and succeed with MESA. If you have any questions,
or concerns, please discuss them with a MESA student staff member or the MESA Director.
To remain an active MESA member the following areas must be met / maintained:
ONE-TIME
1. CAMPUS ASSESSMENT & ORIENTATION: MESA students must complete “Assessment” (take tests or clear
pre-reqs.) and “New Student Orientation” (COUNS 000A or submit a waiver).
2. MESA ORIENTATION (Director will set appointment): New MESA students will attend a 30 minute MESA
Orientation with a MESA student staff member in room C1-118, MESA Study Center, (408) 855-5482.
Date/Time: _______________________________Staff Member: __________________________________________
3. It is HIGHLY RECOMMENDED that MESA Students enroll in COUNS 007, University Transfer Planning, a 1.0
unit CSU/UC transferrable class. Couns. 7 will help you with transfer applications, financial aid, scholarships, etc.
ONGOING
4. ED PLAN: MESA students will submit a current and complete transfer “Educational Plan” to the MESA office every
year. Hard copy or soft copy OK. Email soft copies to “mesa@wvm.edu
”.
5. VOLUNTEER: MESA students must volunteer at least 2 hours a semester for MESA, Mission College, or a
community agency, etc. See the MC “events” webpage or the MESA website for leads. The volunteer form is on our
website.
6. EVENTS: MESA students must participate in at least one MESA event every semester. The event calendar is on our
website.
7. 6.0 UNITS: MESA students are required to enroll in a minimum of 6 units per semester towards their degree objective.
NOTE: A MESA “Compliance Survey” will be distributed via Angel at the end of the semester. Students that fail to complete
the survey or meet the MESA membership requirements above will be deactivated - we don’t want that to happen!
I give my permission for MESA to give my name, phone number, and address to college and employer representatives, and to
use my photograph in MESA and college promotional materials. Yes No
By applying to the MESA Community College Program, I understand that I give my permission for MESA to obtain
information about my performance from colleges and testing agencies, financial aid and other offices to determine eligibility for
the MESA program. You may be asked to provide additional information for eligibility determination.
I certify that I have provided true and correct information.
MCCP Applicant signature
If under 18 years of age, signature
of Parent or Guardian
Date
MCCP Counselor signature
MCCP Director signature
Date
OFFICE USE: __STAL __Excel DB __ ANGEL __Blue folder
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MESA Application And Student Contract 2015-10-06 1 Application Academic Year 200001

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Completed 8 April 2020

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