The Bard College Clemente Course in the Humanities

At Elm Park Community School, Worcester, MA

Hosted by Worcester Interfaith

Application for Admission

To apply:1) Call Elizabeth Bacon at 774-276-1166 to schedule an interview. All interviews will take place at Worcester Interfaith, 111 Park Ave., Worcester, MA 01609 (First Baptist Church)

2) Please fill out this application completely and bring it with you to the interview.

Personal Information

Legal name______

Date of birth ______Sex ______

month/day/year M/F

Home address ______

Number and street, Apt. # city state zip code

Mailing Address (if different)______

Home phone ______Work/other phone______e-mail______

In emergency contact ______

NamePhone

Ethnic or racial heritage (optional) ______First language______

U.S. Citizen ______Permanent resident ______Other status (please specify)______

Entitlements (SSI, WIC, TANF, AFDC etc.) ______

Education

Highest grade completed ______Are you currently in school?______Where?______

Did you graduate from high school? ______When?______Name of School______

Are you a GED recipient? ______Date of GED completion ______Are you currently working toward a GED? ______

Have you ever attended college?______Where? ______For how long? ______

Have you earned college credits? ______How many? ______Why did you leave college? ______

______

Family/ Household

Marital status:◊ single◊ married◊ separated◊ divorced◊ widowed

Do you have children? ______If yes, what are their ages? ______Do they live with you?______

With whom do you live? ◊ alone◊ with parents◊ with spouse or companion◊ with siblings◊ with friends

◊ other arrangement (please specify) ______

(OVER)

What is you annual household income (before taxes)? ◊ under $1,000 ◊ $1,000 - $5,000 ◊ $5,000 - $10,000

◊ $10,001 - $15,000◊ $15,001 - $20,000◊ $20,001 - $25,000◊ $25,001 -$30,000◊ Over $30,000

Employment/Training

Skill/occupation ______

◊ employed full time◊ employed part-time◊ unemployed◊ intern◊ volunteer

Are you currently in a training program? (please specify)______

What other jobs/training have you had? ______

Are you enrolled in other programs (please specify: recovery, therapy, etc.)______

Childcare/Transportation

Will you need childcare to attend these classes? If yes, please specify ages of children______

Will you need bus fare to attend classes? ______If yes, describe cost per class: ______

______

Personal Statement

In the space below, write a statement describing yourself, your interests, your reasons for wanting to take this course and your plans for the future. (c 250 words or more)

Bard College does not discriminate in education, employment, admission, or services on the basis of

sex, sexual orientation, race, color, religion, national origin, or handicapping conditions.