Fillable PASS Application Program for Academic Support Services (PASS) Application

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PASS Application Program for Academic Support Services (PASS) Application

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The PASS Application Program for Academic Support Services (PASS) Application form is 5 pages long and contains:

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  • 51 check-boxes
  • 47 other fields

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PROGRAM/or ACADEM IC SUPPORT SERV ICES
ijDJ
PASADENA
CtTYCOLLEGE
Room D-112
Phone: (626) 585-7815
Fax: (626) 585-7969
2018-19 Application
The Program for Academic Support Services (PASS) is funded by a TRIO/Student Support
Services grant from the U.S. Department of Education.
PASS is an academic support program designed to increase the retention, graduation and
transfer success of PCC students who are low-income, first generation and/or have a disability.
PASS assists participants through effective counseling, academic support and tutoring, exposure
to transfer institutions, and assistance with the financial aid, scholarship and transfer processes.
Who is Eligible to Participate in PASS?
Participants are admitted into the program in a selective process based on the following:
Required Eligibility
U.S. Citizenship or Permanent Residency
Meeting income, first generation and/or disability guidelines
Priority will be given to applicants who:
Are enrolled in 12 (6 units for DSPS students) or more units and have not exceeded 30
completed college units
Have completed the Free Application for Federal Student Aid (FAFSA) for the current
academic year
Are motivated to participate in the program, complete program requirements, and have
a goal to graduate with an Associate degree and/or transfer to a four-year institution
Have an academic need of one or more of the following:
Assessed into or are taking 100-level Math or English course
Have a high school or college GPA below a 2.50
Have withdrawals in degree or transfer courses
Have difficulties passing transfer level courses
English is not the native language
Been out of school five or more years
If you have any questions, feel free to contact the PASS office.
We look forward to helping you reach your educational goals!
STAFF USE ONLY
Date Received: ______________ Approved By: ______________ Date: ______________
Received By: _______________ Director’s Initials: ______________ Date: ______________
STUDENT INFORMATION
Name:____________________________________________________________________________________
Last First Middle
PCC ID#___________________________ Date of birth:______________________________
Address:___________________________________________________________________________________
Street City State Zip Code
Phone numbers: (Home)__________________________ (Cell/Other)____________________________
Email address: ______________________________________________________________________________
Gender:________________ Marital status:______________ Do you have children? Yes No
Are you a former foster youth or ward of the court? Yes No
Ethnicity: (check all that apply)
Hispanic American Indian/Alaska Native Other: ______________________
Asian Black or African-American
(please specify)
White Native Hawaiian or other Pacific Islander
How did you hear about the PASS Program?______________________________________________________
How can PASS best support your educational goals? (Check all that apply)
Academic counseling Transfer counseling
Career counseling Financial Aid counseling
Personal counseling Tutoring
Skill development workshops Financial literacy education
Field trips to colleges and universities Scholarship application assistance
Educational and cultural activities Graduate school preparation
EDUCATIONAL HISTORY AND GOALS
Academic major:__________________________________________________________________________
What is your educational goal at PCC: (check one)
Transfer with an Associate Degree
Obtain an Associate Degree only
Transfer without an Associate Degree
Where would you like to transfer? (Please list in order of preference)
1._________________________________________________________
2._________________________________________________________
3._________________________________________________________
Are you a High School graduate? Yes No
If yes, please list high school name and graduation month and year:__________________________________
High school cumulative GPA: ____________________ Previous Colleges Attended: ______________________
If you did not graduate from high school, did you finish a GED or high school completion program?
Yes No
If yes, please list the month and year you completed the GED:_______________________________________
Have you participated in, or currently in, any of the following programs: (Check all that apply)
Upward Bound Math/Science Upward Bound Veterans Upward Bound
Educational Talent Search Educational Opportunity Center Gear Up
EOP&S/CARE/CalWorks DSPS Puente Program
Ujima Program MESA Project LEAP
CLAVE PCC Athletics PCC Pathways
PROGRAM ELIGIBILITY
Federal regulations state that in order to be eligible for PASS an applicant must: (1) Be a U.S. citizen or permanent
resident, (2) be low-income and/or a first generation college student and/or a student with a verified disability, and (3)
have an academic need. The following questions will help the program determine your eligibility.
Citizenship Status (check one)
United States Citizen
Permanent Resident:
Permanent Resident Card #_________________________________________
(Attach a copy of Permanent Resident card)
Low-Income Verification
To be considered under the low-income criteria you must attach a copy of your 2016 Income tax form (Form
1040, 1040-A, or 1040-EZ). If you are classified as independent, please provide your tax form. If classified as
dependent, also provide the tax forms of your parents.
Did you apply for Financial Aid for this current academic year? Yes No
If yes, are you classified as: Dependent Independent
First Generation College Student Status
Have any of your parents (natural or adoptive) received a bachelor’s degree from a college or university?
Mother: Yes No Don’t know
Father: Yes No Don’t know
Other: Yes No Don’t know
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Disability Verification
Do you have a physical, mental or learning impairment that you need assistance with in order to participate in
the educational opportunities at Pasadena City College? Yes No
If yes, what agency or professional can verify your disability?________________________________________
(Must attach documentation)
Are you receiving services from the PCC Disabled Student Program and Services (DSPS)? Yes No
Academic Need (Please check all that apply)
I tested into or currently taking a 100-level Math and/or English course
I have a high school or college GPA below a 2.50
I have multiple withdrawals (“W”) in degree or transfer courses
I have difficulties passing transfer level courses
English is not my native language
I have been out of school for more than 5 years
Other:____________________________________________________________________________
APPLICATION QUESTIONS
Please answer the following short answer questions. Your responses to these questions are required and will
help the program determine your motivation to participate in PASS. Please write legibly and use complete
sentences. Use the back of the form, or attach an additional paper, if you need more space.
1. What are your educational goals and how do they support your overall career goal?
2. What are potential circumstances that might affect you reaching your academic goal at PCC?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________ ______________________________
3. If admitted into PASS, you will be required to attend counseling appointments and activities each
semester. What will you do to ensure you meet the requirements?
4. Is there any other information that we should take into consideration when reviewing your application,
eligibility, educational history or educational goals? If so, please describe here.
CERTIFICATION & SIGNATURE
I certify that the information submitted on this application is true and correct, and that all documentation is
accurate. I authorize the release of my information and academic records to the Program for Academic
Support Services (PASS) to determine my eligibility for the program and for statistical reporting purposes. I
understand that the goal of PASS is to increase the retention, graduation, and transfer rates of program
participants; therefore, if admitted into the program, I will actively participate in PASS until I complete my
educational goal at PCC.
Student Signature Date
Please submit your completed application to the PASS Office in Room D-112.
Don’t forget to submit all necessary documentation (tax forms, disability verification).
Updated on: 7/6/2018
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PASS Application Program for Academic Support Services (PASS) Application

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Completed 3 November 2019

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