Summer Bridge Application
Summer Bridge is an exciting and valuable week-long orientation to college. During Summer
Bridge, you will have the unique opportunity to live on campus as a college student for five days
and participate activities and workshops designed to prepare you for high achievement at
Central Arizona College and successful transfer to a four-year university.
There is no cost to participate in the Summer Bridge program!
Upon completion of Summer Bridge, eligible students with academic promise will be admitted to
the TRIO program and must enroll in a one-credit Summer Bridge extension course (CPD101)
that meets every Tuesday from 10:30am to 11:45am for 10 weeks during the Fall 2013 semester.
The course focuses on student success and is transferable to university.
Important Dates and Information
When: August 11-15
Who: Recent high school graduates (class of ‘11, ‘12, or ‘13) or GED
Where: Central Arizona College, Signal Peak Campus
Benefits to Summer Bridge Participants
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Learn more about Central Arizona College 
Be assigned a faculty and peer mentor 
Prepare for academic success at CAC and university transfer 
Participate in success skills workshops and the First Year Experience
Become a TRIO participant
Develop personal, academic, and social skills 
Connect to campus staff, faculty, and students 
Experience student life in the residence halls 
Increase opportunities for a higher grade point average (G.P.A.) 
All of these amazing benefits at NO COST to you!!
“Summer Bridge made an outstanding difference in my education and in my
personal life. When I started school I knew many students and I knew the
advisors. Without them I don't think that I would be as successful as I am today.”
Anita Z.—Nursing, CAC
Funded in part by a grant from the United States Department of Education in the amount of $231,103 per year.
TRIO Student Support Services
www.centralaz.edu/summerbridge
Who can attend?
United States citizens or eligible noncitizens who will be first year students
attending CAC in Fall 2013 may apply.
You must fall into one of the following
criteria:
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A first-generation college student, or
From a low-income household
How do I apply?
1. Submit a completed admission
application to Central Arizona College
2. Submit a completed Summer Bridge
application to the TRIO office in M-113
3. Complete the Free Application for
Financial Aid (FAFSA)

What is the FYE?
The First Year Experience consists of
faculty/ staff mentoring, academic advising,
peer mentoring and successful
completion of the one-credit Summer
Bridge Extension course, CPD101.This
course will meet every Tuesday from
10:30am to 11:45am for ten weeks during
the Fall 2013 semester.
Apply now! Space is limited!
For more information on TRIO
Call (520)494-5060
See you in August!
What is next?
You will receive a confirmation packet
notifying you of your acceptance into the
Summer Bridge program. You must return
the RSVP form as soon as possible.
Space is limited!
Return your RSVP form to:
Summer Bridge 2013
Central Arizona College
Attention: TRIO
8470 N. Overfield Road
Coolidge, AZ 85128
trio@centralaz.edu
FAX: (520) 494-5295
TRIO Student Support Services
www.centralaz.edu/summerbridge
Summer Bridge 2013 Application
TRIO Student Support Services
Central Arizona College
8470 N. Overfield Road
Coolidge, AZ 85128
Phone: (520) 494-5060
Fax: (520) 494-5295
Name: ENTER LAST NAME HERE
Last
ENTER FIRST NAME HERE
M.I. HERE
First
MI
Social Security #: XXX-XX-XXXX
CAC Student ID#: 880- XXXXXX
Local Address:
Permanent Address:
ENTER STREET ADDRESS HERE
ENTER STREET ADDRESS HERE
Street
Street
ENTER CITY, STATE ZIPCODE
City
State
ENTER CITY, STATE ZIPCODE
Zip Code
City
Cell Phone: ( XXX ) XXX-XXXX
CAC Email: STUDENT EMAIL
State
Home Phone: ( XXX )
Zip Code
XXX-XXXX
@stu.centralaz.edu Personal Email: ENTER PERSONAL EMAIL HERE
If you live on campus, what is your CAC Mailbox Number? XXX
Gender:
☐ Male
☐ Female
Birth Date: XX/XX/XXXX
☐ Yes ☐ No
Are you a United States citizen:
If not a United States citizen, please indicate your immigration status or
indicate N/A.
Do you identify as Hispanic or Latino?
☐
Yes
☐ No
Are you currently a full-time student?
☐
Yes
☐ No
Ethnic Background: ☐
☐
☐
☐
☐
☐
ENTER HERE OR
N/A
African-American or Black
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
White
Other
Education:
YES/NO High School Diploma
X.X
High School G.P.A.
YES/NO GED
MM/YYYY
SCHOOL NAME
MM/YYYY
High School Graduation Date
High School Attended
Date GED Completed
What is your current student status? (Check mark ONE box.)
☐
☐
☐
1st year student, have never attended before.
1st year student, have attended college previously.
2nd year student with 30 or more credits (sophomore status).
Or,
☐
I already have a certificate, degree (Associate’s, Bachelor’s, Master’s or Doctorate)
from a regionally accredited institution of higher learning.
What is the highest level of education your parents completed?
Father/Guardian:
☐
Elementary
☐
H.S. Diploma
☐
GED
Associate’s Degree
☐
☐
☐
☐
Mother/Guardian:
Bachelor’s Degree ☐ Elementary
☐ Bachelor’s Degree
Master’s Degree
☐ H.S. Diploma
☐ Master’s Degree
Doctoral Degree
☐ GED
☐ Doctoral Degree
☐ Associate’s Degree
Were you living with your natural father and/or mother or an adoptive parent prior
to your 18th birthday?
☐ Yes ☐ No
How did you hear about this program?
☐ Yes ☐ No
Are you currently enrolled at CAC?
Do you know what major/career path you want to pursue?
☐ Yes
If yes, please tell us your program of study/major/career path.
ENTER MAJOR HERE
Do you plan to transfer to a University?
☐
Yes
☐
☐ No
No
TRIO Student Support Services provides many services to participants, all with the goal
of helping you, the student, attain success here at Central Arizona College. All services
and activities are open to all TRIO participants. Please indicate the services and/or
activities in which you may be interested:
☐
☐
☐
☐
☐
☐
Tutoring Assistance
☐ Math
☐ Reading/Writing
TRIO Scholarship Opportunity
Cultural Activities (trips to in-state universities, theater productions, and places of interest)
Study Skills Workshop
Financial Aid Assistance
Career Counseling/Student Employment
Central Arizona College offers a wide range of comprehensive services to students with a
documented disability. If you believe you would qualify for disability student services and
would like more information, please indicate below (circle your response).
☐
☐
Yes
No
I would like more information on Disability Student Services
I am not interested in Disability Student Services at this time.
Do you have a need for assistance with learning English or do you believe your difficulty
with spoken and written English may hinder your success at Central Arizona College?
☐
Yes
☐
No
Income Status:
How many family members live in your household?
NUMBER OF FAMILY MEMBERS
What is your family’s yearly taxable household income?
$XXXXX
Are you currently receiving financial aid?
If no, why?
☐
☐
Yes
☐
No
Have not applied ☐ Not eligible
STATEMENT OF AGREEMENT AND CONSENT:
I authorize the TRIO Student Support Services program at Central Arizona College to review my admission application, placement scores, academic record,
demographic information, financial aid reports, transcripts, and grade point average to determine my eligibility, and provide me with services which will contribute to
my success at Central Arizona College. I understand that data collected, plus the information I provide on this form, will remain confidential, and will be used for
grant reporting to the United States Department of Education.
I understand and authorize TRIO Student Support Services staff to request and share confidential information with the Disability Student Services program, as well
as all information related to violations and/or compliance with Central Arizona College’s Student Code of Conduct.
I authorize TRIO Student Support Services to apply for graduation on my behalf, and I understand that should I fail to pay graduation fees, a hold may be placed on
my account at Central Arizona College. I am aware of the fact that such hold will prevent me from conducting certain business with the college, which may include
the inability to access my Central Arizona College transcripts. I authorize TRIO Student Support Services to obtain tracking information for required reporting to the
United States Department of Education from the National Student Clearinghouse Student Tracker service. I authorize TRIO Student Support Services to send text
messages to the cellular phone number maintained on record with the program. Lastly, I authorize TRIO Student Support Services to obtain periodic reports from my
instructors regarding my academic progress for courses in which I am enrolled. I agree to meet with my peer and/or faculty mentor twice a month at a mutually agreed
upon time. I understand that all information will be kept confidential and will be used only for the purposes specified herein.
Student Signature:
Date:
CLICK TO ENTER DATE
Parent Signature: __________________________________
Emergency Contact Person:
Phone Number:
Emergency Contact Person’s Relationship to You:
XXX-XXX-XXXX
ENTER CONTACT RELATIONSHIP
Return completed application to:
TRIO Student Support Services
Central Arizona College
8740 N. Overfield Road
Coolidge, Arizona 85128
Phone: (520) 494-5060 | Fax: (520) 494-5295
www.centralaz.edu/trio | Email: trio@centralaz.edu