Fillable Summer Bridge Application (Central Arizona College)

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Summer Bridge Application (Central Arizona College)

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TRIO Student Support Services
www.centralaz.edu/summerbridge
Summer Bridge Application
Summer Bridge is an exciting and valuable week-long orientation to college. During Summer
Bridge, you will have the unique opportunity to live on campus as a college student for five days
and participate in activities and workshops designed to prepare you for high achievement at
Central Arizona College and successful transfer to a four-year university.
There is no cost to participate in the Summer Bridge program!
Upon completion of Summer Bridge, eligible students with academic promise will be admitted to
the TRIO program.
Important Dates and Information
When:
July 25-29, 2021
Who:
Recent high school graduates (class of ‘19, ‘20, or ‘21) or GED
Where:
Central Arizona College, Signal Peak Campus
Benefits to Summer Bridge Participants
•
Learn more about Central Arizona College
• Be assigned a faculty and peer mentor
•
Prepare for academic success at CAC and university transfer
•
Participate in success skills workshops and the First Year Experience
•
Become a TRIO SSS participant
•
Develop personal, academic, and social skills
•
Connect to campus staff, faculty, and students
•
Experience student life in the residence halls
•
Increase opportunities for a higher grade point average (G.P.A.)
All of these amazing benefits at NO COST to you!!
“Summer Bridge made an outstanding difference in my education and in my
personal life. When I started school I knew many students and I knew the
Anita Z.—Nursing, CAC
TRIO Student Support Services
www.centralaz.edu/summerbridge
Who can attend?
United States citizens or eligible non-
citizens who will be first year students
attending CAC in Fall 2021 may apply.
You must fall into one of the following
criteria:
How do I apply?
1. Submit a completed admission
application to Central Arizona College
2. Submit a completed Summer Bridge
application to the TRIO office in T204
3. Complete the Free Application for
Financial Aid (FAFSA)
• A first-generation college student
• FAFSA Completed Application
What is the FYE?
The First Year Experience consists of
faculty/staff mentoring, academic advising,
peer mentoring and a personalized
Blackboard based program to be completed
during the Fall 2021 semester and
monitored by TRIO SSS.
What is next?
You will receive a confirmation packet
notifying you of your acceptance into the
Summer Bridge program. You must return
the RSVP form as soon as possible.
Space is limited!
Apply now! Space is limited!
Return your RSVP form to:
Summer Bridge 2021
Central Arizona College
Attention: TRIO
8470 N. Overfield Road
Coolidge, AZ 85128
trio@centralaz.edu
FAX: (520) 494-5295
For more information on TRIO
Call (520)494-5007
See you in July!
Summer Bridge 2021 Application
TRIO Student Support Services
Central Arizona College
8470 N. Overfield Road
Coolidge, AZ 85128
Phone: (520) 494-5007
Fax: (520) 494-5295
Name:
Last
First
MI
Preferred Name:
CAC Student ID#: 880-
Local Address:
Permanent Address:
Street
Street
City
State
Zip Code
City
State
Zip Code
Cell Phone:
(
)
Home Phone:
(
)
CAC Email:
@stu.centralaz.edu
Personal Email:
If you live on campus, what is your CAC Mailbox Number?
Gender:
☐
Male
☐
Female
Birth Date:
Are you a United States citizen:
☐
Yes
☐
No
If not a United States citizen, please indicate your immigration status or
indicate N/A.
Do you identify as Hispanic or Latino?
☐
Yes
☐
No
Are you currently a full-time student?
☐
Yes
☐
No
Ethnic Background:
☐
African-American or Black
☐
American Indian/Alaska Native
☐
Asian
☐
Native Hawaiian or Other Pacific Islander
☐
White
Education:
High School Diploma
High School Graduation Date
High School G.P.A.
High School Attended
GED
Date GED Completed
What is your current student status? (Check mark ONE box.)
☐
1st year student, have never attended before.
☐
1
st
year student, have attended college previously.
☐
2
nd
year student with 30 or more credits (sophomore status).
Or,
☐
I already have a certificate, degree (Associate’s, Bachelor’s, Master’s or Doctorate)
from a regionally accredited institution of higher learning.
What is the highest level of education your parents completed?
Father/Guardian:
Mother/Guardian:
☐
Elementary
☐
Bachelor’s Degree
☐
Elementary
☐
Bachelor’s Degree
☐
H.S. Diploma
☐
Master’s Degree
☐
H.S. Diploma
☐
Master’s Degree
☐
GED
☐
Doctoral Degree
☐
GED
☐
Doctoral Degree
☐
Associate’s Degree
☐
Associate’s Degree
Were you living with your natural father and/or mother or an adoptive parent prior
to your 18th birthday? ☐ Yes ☐ No
How did you hear about this program? _
Are you currently enrolled at CAC?
☐
Yes
☐
No
Do you know what major/career path you want to pursue?
☐
Yes
☐
No
If yes, tell us your program of study/career path and Transfer
college or University._____________________________________
Do you plan to transfer to a University?
☐
Yes
☐
No
TRIO Student Support Services provides many services to participants, all with the goal
of helping you, the student, attain success here at Central Arizona College. All services
and activities are open to all TRIO SSS participants. Please indicate the services and/or
activities in which you may be interested:
☐
Tutoring Assistance
☐
Math
☐
Reading/Writing
☐
TRIO Scholarship Opportunity (FAFSA Eligible)
☐
Cultural Activities (trips to in-state universities, theater productions, and places of interest)
☐
Study Skills Workshop
☐
Financial Aid Assistance
☐
Career Counseling/Student Employment
Central Arizona College offers a wide range of comprehensive services to students with a
documented disability. If you believe you would qualify for services for students with a
disability and would like more information, please place an “X” mark in the box below.
☐
Yes
I would like more information on Student Accessibility Services
☐
No
I am not interested in Student Accessibility Services at this time.
Do you have a need for assistance with learning English or do you believe your difficulty
with spoken and written English may hinder your success at Central Arizona College?
☐
Yes
☐
No
Income Status: Use 2018 Taxes to complete the 2020 FAFSA; 2018 Income below.
How many family members live in your household?
What is your family’s yearly taxable household income?
2018 Taxable income can be found on the line indicated below on each the following tax forms:
Line 43 – Tax form 1040
Line 27 – Tax form 1040A
Line 6 – Tax form 1040EZ
Did you complete the 2020 FAFSA Form?
☐
Yes
☐
No
If no, why?
☐
Have not applied
☐
I think I’m ineligible
STATEMENT OF AGREEMENT AND CONSENT:
I authorize the TRIO Student Support Services program at Central Arizona College to review my admission application, placement scores, academic record,
demographic information, financial aid reports, transcripts, and grade point average to determine my eligibility, and provide me with services which will contribute to
my success at Central Arizona College. I understand that data collected, plus the information I provide on this form, will remain confidential, and will be used for
grant reporting to the United States Department of Education.
I understand and authorize TRIO Student Support Services staff to request and share confidential information with the Student Accessibility Services program, as
well as all information related to violations and/or compliance with Central Arizona College’s Student Code of Conduct.
I authorize TRIO Student Support Services to apply for graduation on my behalf, and I understand that should I fail to pay outstanding fees, a hold may be placed on
my account at Central Arizona College. I am aware of the fact that such hold(s) will prevent me from conducting certain business with the college, which may include
the inability to access my Central Arizona College transcripts. I authorize TRIO Student Support Services to obtain tracking information for required reporting to the
United States Department of Education from the National Student Clearinghouse Student Tracker service. I authorize TRIO Student Support Services to send text
messages to the cellular phone number maintained on record with the program. Lastly, I authorize TRIO Student Support Services to obtain periodic reports from my
instructors regarding my academic progress for courses in which I am enrolled. I agree to meet with my peer and/or faculty mentor twice a month at a mutually agreed
upon time in person, via telephone, or virtually. I understand that all information will be kept confidential and will be used only for the purposes specified herein.
Student Signature:
Date:
Parent Signature (required, even if age is 18 to 26): __________________________________
Emergency Contact Person:
Phone Number:
Emergency Contact Person’s Relationship to You:
Return completed application to:
TRIO Student Support Services
Central Arizona College
8740 N. Overfield Road
Coolidge, Arizona 85128
Phone: (520) 494-5007 | Fax: (520) 494-5295
www.centralaz.edu/trio | Email: trio@centralaz.edu
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Summer Bridge Application (Central Arizona College)

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Completed 1 April 2021

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