Gateway to College

Application for Admission

Please read the application carefully before completing it. PRINT clearly in blue or black ink. Be sure to complete the entire application and required essays. Please return your completed application to your counselor.

DATE OF APPLICATION: ______

NAME AND ADDRESS

Full Legal Name: ______

Last First Middle Initial

Phone Number: ( ) ______-______Email address: ______

High School ______MSIS number ______

Current Home address: ______

Street Address

City: ______State: ______Zip: ______

Mailing address (if different from home address): ______

Street address or PO Box #

City: ______State: ______Zip: ______

II. Personal Information/Emergency Contact Information

Date of Birth: ___/____/____ Current age: ______Current grade level: ______

Parent/Guardian: ______Relationship to you: ______

Parent/Guardian email address: ______

Parent/Guardian phone numbers: (____) ______(____) ______

HomeCell

Place of employment: ______Work Number: (___) ______

With whom do you live? ______

Applicant Name: ______

III. Academic Information

Name of School: / Location
(City/State) / Dates (Month/Year – Month/Year) / #of credits earned / Last grade attended

Have you ever received Special Education Services, an Individualized Education Plan (IEP), or a 504 plan? _____Yes ____No?

If yes, please answer the following questions:

Current or most recent school attended:______
Name of school counselor:______
What type of IEP do you have (or what kind of services were you receiving)?

______

Have you taken the ACT? ______If so when did you take it? ______

Have you ever been dismissed or suspended from a school or college for any violations of student conduct or safety? If yes, please explain. What kind of support would you need to ensure that this behavior does not occur again?

______

Is there anything that may prevent you from attending classes on a regular basis? ____No _____Yes. If yes, please explain: ______

______

Usual Gateway to College class times: 8:00am until 3:00pm Monday – Friday.

IV. EMPLOYMENT

Do you currently have a job? ______Yes ______No Ifyes, please complete the following:

Employer: ______Approximately how many hours a week do you work? _____

V. REFERRAL INFORMATION

How did you learn about this program? ______

Applicant Name ______

VI. REQUIRED SIGNATURES

I certify that the information on this application is correct and complete. I understand that if I have not provided accurate information or the required application materials, I may be denied acceptance in the Gateway to College program.

I also understand that I cannot be enrolled in any other high school of other alternative high school education program while participating in the Gateway to College program. If selected for the program, I agree to abide by the Hinds Community College and RCSD student handbooks as well as the policies and procedures of the Gateway to College program.

I also understand that I am required to attend classes Monday – Friday from 8:00a.m. to 3:00p.m. and that I am required to be available during these hours for classes, tutoring, and state testing.

I hereby authorize HCC to release confidential information about me contained in the college records to my school district and parent/guardian. I also authorize my school district to release confidential information about me to HCC and my parent/guardian.

Hinds Community College, in its educational policies, programs, and procedures, provides equal opportunity for all its students without regard to race, color, national or ethnic origin, religion, sex, sexual orientation, or disability.

Applicant Signature: ______Date: ______

Parent/Legal Guardian Signature: ______Date: ______

Parent/Legal Guardian must sign the application if the applicant is under the age of 18.

High School Principal Signature: ______Date: ______

District Superintendent Signature: ______Date: ______

VII. PHOTO/VIDEO RELEASE

Photographers/videographers employed or contracted by Hinds CC regularly take photographs/video of people, either individually or in a group, to illustrate or describe various aspects of the college and campus life. These photographs/video will be taken at public venues. Or they may be taken in organized campus photo/video shoots where the subjects will have given verbal consent to be photographed/videotaped. Individuals who are photographed/videotaped while attending a public event or who verbally agree to participate in a photo/video shoot will be understood to have authorized Hinds CC to use their likeness in print and electronic materials to promote the College. The College will retain the usage rights to the photographs/video in perpetuity.

To avoid having this information released, the student must submit a written request to the Gateway to College Office within 10 classroom days, not including Saturdays, Sundays, and holidays. After the initial 10-day period, any new request for withholding of directory information shall require a 10-classroom day, not including Saturdays, Sundays, and holidays, written notice to the campus Gateway to College Office to become effective.

Applicant Name: ______

Application for Admission – Essay Requirements

VII. THREE ESSAYS

These essays will be used by the selection committee to decide between many applicants. Please use the essays to help your application by following all the instructions.

This essay portion of the application helps us become acquainted with you on a more personal level and is an important step in the final acceptance by the Gateway Selection Committee. Your application is not complete without your essays and will not be considered for acceptance without receiving them by the announced deadline.

DIRECTIONS: On separate sheets of paper, write answers to the three essay questions below. Each essay should be at least two (2) paragraphs, in essay format, typewritten, and double-spaced. Each essay can be more than 2 paragraphs, but please don’t submit essays that are fewer than 2 paragraphs in length. If you do not have access to a computer or typewriter, you may neatly hand write your answers in ink. Please write your name on each page. Attach the essays to your application form.

Please respond to all of the following questions. Be sure to answer all questions in your essays:

ESSAY I

What personal strengths have helped you overcome challenges in your life? How will your strengths help you to attain your educational goals? Talk about some key personal problems or challenges that you have had that have interfered with your success in completing your education in the past. What would be different now?

ESSAY II

Why are you interested in being a part of Hinds Community College’s Gateway to College program? Why do you think this program is a good fit for you to achieve your goals? Why should the selection committee choose you for this scholarship program, especially since there is a lot of competition for limited slots?

ESSAY III

As a full-time college student, how would you balance your coursework, employment, family, social, and personal life? What would motivate you to attend classes 100 percent of the time? What would motivate you to complete all your homework assignments on time?

Counselor’s Checklist

Applicant Name ______

______Please attach a copy of students cumulative record insert sheet.

______Please attach a copy of discipline report.

______How many days has the student missed this semester?

______Does this student have and IEP? ____YES ___NO Ifyes, please attach a copy.

State Test

Please place a √(check) in the space provided to indicate whether the student has taken the following state tests. Pleasecircle if student passed the test and list the passing score. If the student failed the state test, list the failing score and the grade received in high school.

U.S. History: _____Yes or _____No Passed-Yes ______or______/______

Algebra I: _____ Yes or _____No Passed-Yes______or ______/______

English II: _____Yes or _____No Passed-Yes______or ______/______

Biology I: _____ Yes or ____ No Passed-Yes______or ______/______

ACT: Yes___ or No___ Scores: English ______Math ______Reading ______Biology

Counselor’s Signature: ______Date:______

Dr. Young’s Signature: ______Date:______

Please keep a copy for your records.

Hinds Community College offers equal education and employment opportunities and does notdiscriminate on the basis of race, color, national origin, religion, sex, age, disability or veteran statusin its programs and activities. The following person has been designated to handle inquiries regardingthe non-discrimination policies: Dr. Debra Mays-Jackson, Vice President for Administrative Services, 34175 Hwy. 18, Utica, MS 39175, 601.885.7002.