University of Missouri-Kansas City
Academic Support and Mentoring
Summer Bridge Program
5000 Holmes Street, ASSC Bldg., KCMO 64110
816-235-1178 Fax 816-235-5156
SUMMER BRIDGE SCHOLARS STUDENT ADMISSIONS APPLICATION
INSTRUCTIONS: You must fill out all sections of this application completely and honestly. Application is due back by March
15, 2016. This information will be used to determine your eligibility for the program.
Please TYPE on this form or PRINT (use black or blue pen).
Submit by mail or fax using the contact information above, or electronically to koernerp@umkc.edu.
Date _______________________________
Applicant Name
Middle
First
Preferred Name
Last
Preferred Pronoun (he, she, ze)
Address
Apt.#
City
State
Zip Code
Primary Phone
Alt. Phone (Please specify)
Email Address
Parent(s)/Guardian(s) Name(s)
Parent(s)/Guardian(s) Email Address(es)
Person to Contact In Case of Emergency
Full Name
Relationship
Home Phone
Full Name
Relationship
Home Phone
STUDENT BACKGROUND INFORMATION
Name of High School
Non-Athletic Extracurricular Activities (Check all that apply)
Academic Honor Grps
Band
Boy/Girl Scouts
Chess Club
Debate
Debutant
Drama Club
Drill Team
Math Club
Pep Club
ROTC
Science Club
Student Government
Other (Please specify)____________________________________________________________
Athletic Activities
Hobbies/Interests
Please describe your involvement in your community.
What has been your greatest accomplishment?
I plan to attend UMKC in the fall of 2016.
Yes
Possible College Major(s)
No
Career/Life Aspirations:
The UMKC Summer Bridge Program is an 6-week academic opportunity that requires a full-time commitment, which
involves living on-campus, not working a job, and not having a car for the duration of the program. Please indicate below that
you are able to meet this commitment.
Yes, I am prepared to make this commitment
In the space provided or as an attachment, please complete the following essay questions:
What interests you about participating in this program? (250 word limit)
Tell us about your ability to persevere in a challenging situation. Please provide an example. (250 word limit)
PLEASE READ CAREFULLY AND SIGN – I certify that the above statements are correct. I understand that any false information (or
omissions) in this application, or its supporting documents, will be sufficient for dismissal from the program or refusal to admit me or my daughter/son
into the Summer Bridge program.
___________________________________________________________________________________________
Parent(s)/Guardian(s) Signature(s)
Date
________________________________________________________________________________________________________
Student’s Signature
Date
NOTICE OF NONDISCRIMINATION: Per Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, and Section 504 of the Rehabilitation Act of 1973, the
University does not discriminate on the basis of race, color, religion, national origin, ancestry, sex, age, disability, or status as disabled veteran or veteran of the Vietnam Era. Any person having
inquiries concerning the University of Missouri’s compliance with these regulations is directed to contact the campus Affirmative Action Office, 223B Administrative Center 816-235-2721.