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: ________________________
I. NAME AND ADDRESS
Full Legal Name: ________________________________________________________________
Last
First
Middle Initial
Phone Number: (
) ________-____________
High School _____________________________
Email address: ________________________
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: (____) __________________ (____) _______________________
Home
Cell
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 If yes, 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 8:00 a.m. to 3:00 p.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 If yes, 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. Please circle 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
not discriminate on the basis of race, color, national origin, religion, sex, age, disability or veteran
status in its programs and activities. The following person has been designated to handle inquiries
regarding the non-discrimination policies: Dr. Debra Mays-Jackson, Vice President for Administrative
Services, 34175 Hwy. 18, Utica, MS 39175, 601.885.7002.