SCHOLARSHIP APPLICATION
For GATEWAY TO COLLEGE PROGRAM
Please read the entire application carefully before completing. Print clearly. Use a black or blue ink pen.
Only complete applications will be considered.
Today’s Date
Applying for:
□ Fall Semester
□ Spring Semester
Application Deadline _________________________
Year
Student Information
Social Security Number
Last Name
Middle
Initial
First Name
Physical Address
Apt #
City, State, ZIP
Student Home Phone
(
)
Student E‐mail
Address
Student lives with
Name:
Relationship:
Parent Cell
Parent Work #
Student Cell
Student Work #
Alternate Contact
Phone(s)
Additional Contact
Phone(s)
Contact Name & Cell
Contact Name & Cell
Ethnicity (check one)
Date of Birth
/
Birthplace
City
Language(s) Spoken
at Home
□ Asian/
Pacific
Island
□ White/
Caucasian
/
□ Black/
African American
Current Age
□
Hispanic/
Latino
□ Native/
American/Alaskan
Gender (check
□ Male
one)
□ Other
(specify)
□ Female
State
First language
Country
Second language
Academic Information
Your School District
Currently enrolled in
School?
If yes, which high
school?
□ Yes
□ No
Grade:
If no, give date and last
high school attended
High school credits
earned
Student Name
Page 1 of 7
(Please attach a transcript from each high school attended.)
List all high schools, alternative programs, or home school where you have taken courses, beginning
with the most recent. Use a separate sheet if more space is needed.
Location
(City, State)
School
Ex: ABC High School
Anywhere, TX
Dates of
Attendance
# of credits
earned
01/03‐05/2004
2.5
Grade level
when last
attended
9th grade
Emergency Contact #1
Full Name:
Last
Address:
Street Address
First
M.I.
Apartment/Unit #
City
Primary
Phone:
(
State
)
Relationship:
Place of
Employment:
Alternate
Phone:
(
)
Work
Phone:
(
)
Zip code
Emergency Contact #2
Full Name:
Last
Address:
Street Address
First
M.I.
Apartment/Unit #
City
Primary
Phone:
(
State
)
Relationship:
Place of
Employment:
Alternate
Phone:
(
)
Work
Phone:
(
)
Zip code
Employment
Work status does not affect your eligibility as long as work hours do not conflict with class hours. This
information will help El Paso Community College determine your schedule.
Are you currently
No
Yes (Part Time 3‐20 hrs/wk)
Yes (Full Time 21+ hrs/wk)
employed?
Work Location:
Work Phone:
Student Name
(
)
Supervisor
Name:
Page 2 of 7
OTHER
Have you ever been dismissed or suspended from school
or college for any violations of student conduct or
safety? If yes, please explain.
Are you currently court‐mandated to attend school? If
so, please provide copies of all legal documents.
Do you have a 504 Plan or an Individualized Educational
Plan (IEP)? If so, will you be requiring services outlined
in one of these plans? Please specify.
Court/Judge:
What career area or college major interests you?
Is there anything that may prevent you from attending
classes on a regular basis?
Transportation
Child Care
Illness
Work
Other, Specify
What assistance and resources would you need to help
deal with the things you listed above?
Referral Information
Administrator
How did you learn about this
program?
(Name)
(School )
(Name)
(School )
Counselor
Friend / Other
Signature
I certify that the information contained in my application is correct and complete. I understand if I have not
provided accurate information or required application materials I may be denied acceptance for the
upcoming semester to the Gateway to College scholarship.
I also understand that I may not be enrolled in any high school or any other alternative high school education
program while participating in the Gateway to College scholarship program. If selected for the scholarship, I
agree to abide by the policies and procedures of the Gateway to College Program and El Paso Community
College.
EL Paso County Community College District does not discriminate on the basis of race, color, national origin,
religion, gender, age or disability veteran staus, sexual orientation, or gender identity. For special
accommodations issues or an alternate format, contact El Paso Community College Disability Support
Services at (915) 831‐2676.
Applicant Signature:
Student Name
Date:
Page 3 of 7
STUDENT CONSENT TO RELEASE INFORMATION
El Paso Community College shall follow all applicable state and federal laws, rules and regulations that apply to student
records. All information contained in the college records which is personally identifiable to any student shall be kept
confidential and not released except upon prior written consent of the student or upon the lawful subpoena or other
order of a court of competent jurisdiction.
I authorize El Paso Community College, or any third party it has approved, to record my image, voice on film via
photograph, picture, and/or videotape. I further agree that any recording may be shared at the sole discretion of El Paso
Community College, or any third party the college approves.
I hereby authorize El Paso Community College to release confidential information about me contained in the college
records. I also authorize my school district to release confidential information about me to El Paso Community College.
Student Last Name
First Name
M.I.
Date of Birth Social Security #
Release to (please select all that apply):
El Paso Community College / Gateway to College Staff
Sponsoring School District Name:
Parent/Guardian/Support Person:
Name
Address
Relationship
Phone Number
Name
Address
Relationship or
Phone Number
Agency (if applicable)
Information that will be released through authorization of above signature:

name, address and phone
 transcript of grades

date of birth
 verification of attendance

last high school attended and date
 test score and progress information

disciplinary action
 date of graduation and program of study
To indicate that you understand all of the above and the information that will be released, please sign below:
Student Signature & Date:
PARENTAL APPROVAL FOR RELEASE OF INFORMATION &
ENROLLMENT IN GATEWAY TO COLLEGE PROGRAM
PLEASE READ CAREFULLY
I hereby grant
permission to enroll in the Gateway to College scholarship program at El Paso
Community College. I understand that the exact length of time to earn a high school diploma varies by a student’s course
load and credit needs.




Gateway to College is not a fast‐track program for high school completion.
It may take a student 18 months to 3 years to receive a high school diploma through the Gateway to College
program.
Students may earn college credit toward an associate degree or earn an associate degree through the Gateway
to College program.
Students may remain in the Gateway to College program only until they earn a high school diploma or reach 21
years of age.
Parent / Legal Guardian (please print name & relationship):
Parent / Legal Guardian Signature & Date:
Student Name
Page 4 of 7
APPLICATION FOR ADMISSION ESSAY
Directions:
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 of the Gateway to College Selection Committee.
Your application is not complete without this typed essay and will not be considered for acceptance
without receiving it by your announced deadline. Each topic includes questions you can ask
yourself to help you write your essay. Each answer should be at least (2) two paragraphs per topic.
Please type your name and the date on each page. Attach the Application for Admission Essay
to your completed application.
Essay Topics:
1. Your Strengths – What personal strengths have helped you to survive and/or to get back up
and keep trying? What strengths have helped you to make friends and/or to make positive
relationships with adults? What strengths have helped you to say “no” to peers who try to
distract you from your goals in life?
2. Problems and Challenges – What are some key personal problems or challenges that have
interfered with your success in completing your education in the past? (i.e. attitude,
behavior, motivation, skills, feeling accepted, cultural barriers, etc.) What would be
different now? Describe your commitment & motivation to overcome these challenges at
this time in your life. How will the strengths you described above help you to overcome
your challenges and to be successful?
3. Your Interest in Gateway to College – Tell us why you are interested in being part of the
Gateway to College Program at El Paso Community College. (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‐based program especially since there is a lot competition for
limited slots? Explain each area.)
4. Your Motivation – As a full‐time college student, how would you balance your schoolwork,
employment, family, social, and personal life? What would motivate you to attend classes
100% of the time? Explain all areas.
Student Name
Page 5 of 7
THIS FORM SHOULD BE TAKEN TO THE LAST SCHOOL ATTENDED
School District Information Form
This form is being brought to you by a student who is applying for Gateway to College
Scholarship program through EPCC.
In order to assess whether Gateway to College can meet the applicant’s educational needs, we
are requesting their transcript and a copy of their Individual Education Plan (IEP) or 504 plans,
where applicable.
Applicants who have an IEP (or 504) can only be accepted to Gateway to College after an IEP
meeting is held. A EPCC representative must be present to determine if our programs are able to
meet the educational needs of the student. Please contact Cynthia Aguilar, Director Gateway to
College, at (915) 831‐4700.
EPCC accepts students 16‐20 from school districts that have contracts with us. We currently have
contracts with the districts listed below.
Student Name
Page 6 of 7
COUNSELOR APPROVAL FORM
Entering Semester:
FALL
SPRING
YEAR
Date:
Student Information
Name:
SS#
Address:
D.O.B
Age:
Zip Code
Alternate Phone #
Phone #
To Be Completed By High School Counselor
High School:
Transcript
o attached
o faxed
o mailed
o other
EOC/TAKS Results & Profiles
Special program Participation
The applicant does not have an IEP or 504.
The applicant does have an IEP or 504.
The IEP team will meet on the following date to determine if placement into EPCC is
appropriate:
(Please contact Cynthia Aguilar at (915)831‐4700
Approved by:
Counselor Phone:
(Counselor Signature)
(Counselor Printed Name)
Fax:
Counselor Email:
GATEWAY TO COLLEGE STUDENT ELIGIBILITY REQUIREMENTS




Prospective student must have this form completed and signed by referring/approving counselor.
Prospective student is at least 16 years of age.
Prospective student must complete graduation requirements by the age of 21.
Prospective student must reside and be enrolled in one of the participating school district
boundaries.
* For additional information call the Gateway to College Office: (915)831‐4700, Fax: (915) 831‐4702
Mail correspondence to: El Paso Community College, PO Box 20500, El Paso, TX 79998
Student Name
Page 7 of 7