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Please take care to write legibly. Thank you.
Pathways to College Associate Scholars will receive material periodically to encourage their efforts to prepare for college and
inform them of opportunities that may be of interest. In addition, names of juniors will be forwarded to colleges with which
Pathways to College is affiliated. Associate Scholars also have access to Pathways to College staff. Please answer all questions
to the best of your ability. All personal information is used anonymously for statistical purposes only. Thank you.
Female
Male HS Graduation Yr: ________
Name: __________________________________________________________________
Last
Circle Current Grade:
First
9
10
11 12
Home Address: __________________________________________________________
Number and Street
Apt Number
Date of Birth ___________________________
_________________________________________________________________________________
City
State
Zip
Social Security # ____________________________
Month/Day/Year
Are you a U.S. Citizen? Yes ___ No ___ If not, do you have a green card? Yes ___ No ___ Green Card # ____________________________
Parent e-mail __________________________@ ________________________ Contact by:
Home Telephone (________) _____________________________
Home Phone
Cell/Work Phone
e-mail
Parent Work or Cell (________) ______________________________________
Would you prefer to receive some of your Pathways information by email? Yes _____ No______ If yes, to what email address should
Pathways materials be sent? (PRINT Clearly) _______________________________________@_______________________________________
(NOTE: the email address (es) provided will be used ONLY by Pathways to College.)
High School attending or will tend_____________________________________________City_______________________State ______________
Counselor Name (if known) _________________________________________________Tel. No. (______) _______________ext. _____________
What was your average grade last year? _________________ If applicable, what is your average grade this year? _____________________
Applicant requirements: an academic record that demonstrates interest in and potential for academic growth and leadership
With what ethnic group do you most identify?
African American
Asian American
Native American
Hispanic American
Other (Specify) ____________________________
Language(s) spoken at home? ____________________________________ Number of younger siblings at home? _______ Older? _________
With whom do you live?
Mother
Father
Both Parents
Parent and Step-Parent
Grandparent(s)
Other ______________________
Father/Male Guardian: Name ____________ _____________________________ Occupation _________________________________________
Highest grade completed (e.g., 6, 9, 12, 13, 14, 16) ________________ Degree attained, if applicable ___________________________________
Mother/Female Guardian: Name ______________________________________ Occupation __________________________________________
Highest grade completed (e.g., 6, 9, 12, 13, 14, 16) ________________ Degree attained, if applicable ___________________________________
What is your household’s approximate annual income level?
$20,000 - $29,999
$30,000 - $39,999
Check the type(s) of colleges that interest you:
Public Assistance
$40,000 - $59,999
4-year
What careers interest you? (Circle numbers)
1. Architecture/Engineering
2. Arts
3. Business/Finance
7. Legal
8. Military
9. Social Services
$0 - $14,999
$60,000 - $79,999
2-year
$15,000 - $19,999
$80,000 - $99,999
out of state
$100,000 and above
in-state
4. Computer/Math
5. Education
6. Health/Medicine
10. Other (Specify) ____________________________________________
What activities (school and community) are you involved in? If there are activities you plan to be involved in, list them also
Activity
Dates or school year of participation or when
you expect to participate
Position (e.g., member, secretary, etc.), Award, Honor, or
other comments
Please complete page 2. Do not forget applicant and parent or guardian signatures!
Document1
© Pathways to College 2014
Page 2. Applicant Name (Please Print) _________________________________________________________________________
Compare yourself to other students in your grade by putting checks in the grid below:
Self-Evaluation
Outstanding
(1)
Excellent
(2)
Good
Average
(3)
(4)
Below
Average
(5)
Comments (Optional)
My academic ability is
My social skills are
My writing ability is
My study skills are
My ambition is
My judgment is
My leadership is
My athletic ability is
My math ability is
My creativity is
My verbal ability is
My reading ability is
Each day you come into contact with situations and/or people that influence you and the choices you make. Describe in the
space below, or on a separate piece of paper, a person or situation that has had either a negative or positive effect on you.
__________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Pathways to College Associate Scholar Commitment:
If accepted into the program, I agree to the following:
 To be responsible in all school classes and activities.
 To use and search out the resources that will bring me closer to achieving my educational and personal goals.
 To act in ways that show respect for myself and others at all times.
Applicant Signature _______________________________________________________________Date _________________
Parent/Guardian Commitment: If my child is accepted as an Associate Scholar, I will take an active and constructive role in my
child’s education by attending relevant school meetings and being aware and supportive of his/her responsibilities. I give permission
for the applicant to participate in photographs, films or interviews as they pertain to Pathways to College for the purpose of
demonstrating the progress of Pathways to College students and promoting or publicizing the Pathways to College program. I also
consent to allow the organization to obtain post-secondary enrollment information from the National Student Clearinghouse. I
further understand that, if accepted, the applicant’s name and address will be given to Partner Colleges of Pathways to College, but
that all other data about the applicant and the applicant’s family is confidential and will be used only anonymously to help
document the collective achievements of Pathways to College Scholars and Associate Scholars.
Parent/Guardian Signature __________________________________________________________ Date _________________
Please return the completed form to:
Document1
Pathways to College
Programs Office
P.O. Box 2105
Middletown, NY 10940
© Pathways to College 2014