1
Jewish Vocational Service Application for Admission
Bridges to College Program
29 Winter Street 3rd Floor, Boston, MA 02108
Name:_______________________________________________________
How did you hear about the Bridges to College Program?
_________________________________________________
_____________________________________________
_____________________________________________
Please complete all sections of this application before your interview appointment.
Bring this completed application to your interview appointment at JVS. Failure
to complete this application before your interview may result in rescheduling your
interview appointment or delay acceptance into this program.
If you have additional questions, please contact Brian Moore at (617) 399-3244
or email at bmoore@jvs-boston.org or Sharon Zammuto at (617) 399 -3248 or
email at szammuto@jvs-boston.org
2
Application Directions and Required Documents
for Admission
 Complete and bring this application and documents listed below to your
interview appointment (Please bring the forms you have to your
interview).
 Please check the forms you will bring to your interview.
High School diploma/GED/transcript (translated into English if
applicable) or HiSET (High School Equivalency Test) documentation
Birth Certificate or U.S. Passport or Permanent Resident Alien Card
(Green Card) or I-94 card
2 Proofs of Massachusetts Residency with your name and address (e.g.,
Driver’s License or MA Identification Card, apartment lease, utility bill,
bank statement, employment paycheck stub, cell phone bill, DTA letter)
Proof of income, W2 Tax Forms, Tax Returns from previous year
Previous College Degree and College Transcript (college courses and grades)
Certificates for completed Training Programs (CNA, Medical Asst, Pharm Tech, etc)
Resume (if you have one)
Selective Service Registration Confirmation form (for males between 18-25 years old)
3
General Studies
What level/type of college degree or vocational training are you interested in earning/receiving?
License
Certificate
Associate’s
Bachelor’s
Master’s
Ph.D.
Other:_____________
What program of study/major/field(s) are you interested in studying in college?
___
Education/Teaching
___
Computer/Information Technology
___
Accounting
___
Social Sciences (psychology, sociology, government)
___
Business/Management
___
Arts/Humanities
___
Medical/Health/Nursing
___
Engineering
___
Lab Science (Biology, Chemistry)
Other Program of Study:_______________________________
___
Clean Energy (HVAC/R, Solar Energy)
What college(s) are you interested in attending?
College Choice #1
_____________________________________________________
College Choice #2
_____________________________________________________
College Choice #3
_____________________________________________________
Have you ever attended Bunker Hill Community College?
When did you attend Bunker Hill Community College (Year)?
Yes
No
___________________________________
Which program did you study?_______________________________________________________________
Have you completed ESL classes at a college/agency before?
Yes
No
If Yes, at what college/agency did you complete the ESL classes?____________________________________
Are you currently enrolled in a college program?
Have you taken classes at:
JVS
Crittenton Women’s Union
International Institute of Boston (IIB)
El Centro del Cardenal
Are you currently enrolled in any other educational program?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
Year Up
AACA
BCNC
No
Yes No
Yes No
Yes No
If Yes, where? _____________________________________________________________________________
4
Personal Information (Please Print Clearly):
Name:
_________________________________________________________________________________
First Name
Middle Name
Last Name
Former Name (if any)
Residence address:
________________________________________________________________
Mailing address:
________________________________ ________________ ______________________
City
State
Zip
________________________________________________________________
(if different from above)
________________________________ ________________ ______________________
City
State
Zip
Telephone number:
Home
Cell Phone
E-Mail Address:
Emergency Contact: __________________________________
Name
____________________________________
Relationship
Emergency Contact Phone:
Emergency Contact Info: _________________________________ _____________________ ____________
Address
City, State
Zip
Birth Date: _____________ /________ /_________
Month
/ Day / Year
Gender:
Female
Male
Current marital status:
Ethnicity:
How old are you? ________
Social Security Number: ________________________________
Single
Divorced
Separated
Married
Domestic Partner
Legally Separated
Married, but not living together
Common Law
Widowed
Black
White
Other
Asian/Pacific Islander
Native American/Alaskan Native
Not Disclosed
Race:
Hispanic
Not Hispanic
Citizenship Status:
U.S. Citizen
Political Asylum
Cuban/Haitian Entrant
Refugee
Permanent Resident (Alien)
Temporary Resident Status (TPS)
Other (please specify):____________________________________________________
Not Disclosed
5
What is your first language?________________________________________________________________
What other languages do you speak? _________________________________________________________
What is your country of origin? ____________________________________________________________
If you are an immigrant, when did you arrive in the U.S.?
________________/_________/____________
Month
Day
Year
Alien Registration (Green Card) Number: _____________________________________________________
I-94 Number (white card/A #):
A:__________________________________________________________
Education History
What is your highest level of education? (please check only one option)
____ HiSET (High School Equivalency Test, formerly known as GED)
____
High School Diploma
____
Foreign High School Diploma ____ Some College (no degree)
____
Associates Degree
____
Bachelor’s Degree
____
Master’s Degree
____
Doctorate Degree
High School Information
Do you have (check 1) High School Diploma ____ GED/HiSET(High School Equivalency Test)
Foreign High School Diploma ____
___
Name of High School/Agency: ________________________________________________________________
City: ______________________________ State: _________ Country:_______________________________
Graduation Date (month/year): ___________________________________________________
Do you have your original high school diploma/GED/ Foreign High School Diploma/HiSET(High School
Equivalency Test?
Yes No
If Yes, is the diploma translated in English?
Yes
No
College or University Information
Have you ever attended college?
Yes
No
(please complete the next section only if you previously attended a College/University (including taking college level
classes without graduating from the college or attending college in another country and/or United States)
College or University Name: __________________________________________________________________
City: ______________________________ State: ______________
Country: _________________________
Start Date (Month/Year)___________/____________ to End Date (Month/Year)____________/____________
Major/Area of study:_________________________________________________________________________
Did you complete program/graduate?
Yes
No
Are you able to provide a college diploma and transcript (list of courses and grades)?
Yes
No
6
Employment Information:
Have you worked in the past year?
Yes
No
If you responded No to previous question, please provide a brief explanation of why you have not worked:
________________________________________________________________________________________
Are you currently working?
Yes
No
How many approximate hours do you work per week (if you work more than 1 job, please add hours from all
jobs together)
Less than 10 hours/week
10 – 20 hours
20 – 30 hours
Does your work schedule change every week?
Yes
30 – 40 hours
More than 40 hours
No
If not working, how many months have you been unemployed? ____________________
Are you looking for work?
Yes
No
If Yes, are you looking for full-time or part-time work?___________
If not working, how do you support yourself? Please explain:
________________________________________________________________________________________
If you are married, does your spouse work?
Yes
No
How many approximate hours does your spouse work per week (if he/she works more than 1 job, please add
hours from all jobs together)
Less than 10 hours/week
10 – 20 hours
20 – 30 hours
Does your spouse's work schedule change every week?
Yes
Do you receive any financial assistance from the government?
30 – 40 hours
More than 40 hours
No
Yes
No
If you responded Yes to previous question, what type of monthly financial assistance do you receive from the
government? Check all that apply.
____ Food Stamps
____
Rent Assistance
____
Child Support
____
Cash Assistance
____
Subsidized Housing
____
WIC
____
Social Security
____
Social Security Disability
____
Unemployment
____
Public Transportation
____
Other __________________________________________
7
Please include your last five years of employment history, starting with your most current
job (please also include jobs you worked in other countries)
Name of Company
(include city and country)
Job Title
Dates of Employment
(Month/Year)
Start Date:
End Date:
/
/
Start Date:
End Date:
/
/
Start Date:
End Date:
/
/
Start Date:
End Date:
/
/
Start Date:
End Date:
/
/
Reason for leaving
8
Income Information
This information is important for financial aid eligibility and planning to pay for college. If you are not currently working or have
worked for less than 1 year, please estimate the yearly income.
Parents’ income information is important if you are under the age of 24 (even if parents live outside of the United States) or you are
currently living with parents.
Current Source of
Income
Your Income
Hourly Wage
Monthly income
$
$
Total Yearly Income (Monthly
Income for 12 months)
$
Spouse Income
$
$
$
Parent (s) Income
$
$
$
Child Support
N/A
$
$
Unemployment
N/A
$
$
DTA (Government
Assistance)
Other Source(s) of
income
Total
N/A
$
$
N/A
$
$
N/A
$
$
Please circle one of the income ranges for your current annual combined family income (from total above)
$21,000 or less
$21,001 to $28,000
$28,000 to $35,000 $35,001 to $42,000
$49,000 to $56,000
$56,001 to $63,000
$63,001 to $70,000 $70,001 or more
Please place a check mark
next to
$42,000 to $49,000
all of the following expenses you are responsible (or
you assist with paying) for in your household. (We are not asking for the
$ amount of these expenses).
___
___
___
___
___
___
___
___
___
Rent
Home Mortage/Insurance
Car payments/Insurance/Maintenance
Utilities (electricity, heat)
Telephone/Cell Phone bill
Sending money to family in home country
Children attending college
Education Costs (student loans, tuition)
Money given to religious institution
___ Health Insurance
___ Health Care/Medical Bills
___ Bus/Train transportation
___ Cable/Internet
___ Supporting family in U.S.
___ Supporting Parents/Grandparents
___ Food/Groceries
___ Child Support
9
Family Demographics
Are you a parent of children under the age of 18?
Are you a
Yes
No
____Custodial Parent (the child’s primary guardian, the one the child lives with most of the time)
____ Non-Custodial Parent (a parent who does not have physical or legal custody of his/her child
by court order)
____ Not a Parent
Including yourself, how many people (husband/wife, children) are in your family?
___________
Please list all members of your immediate family (parents, grandparents, spouse, children, brothers, sisters):
First Name
Last Name
Age
Relationship
to you
Do they
currently
live with
you?
Is this
person
currently
working?
Is this person
attending
school/college?
10
Childcare
One of the most common reasons for a student not completing a program
is back up childcare.
If your child is sick or his/her school is closed on a day you will be expected to be in JVS classes and
the following person(s) are available to care for your child while you attend classes.
Name of Child
Age
Name of School or Child
Care Provider
Telephone
Drop
off
time
Pick
up
time
WHO CARES FOR YOUR CHILD WHEN SCHOOL /DAY CARE IS CLOSED, WHEN YOUR
CHILD IS SICK OR WHEN YOUR BABY SITTER IS NOT AVAILABLE?
NAME: ______________________________________________
TELEPHONE: _______________________________
Do you plan to travel within the next 6 months?
Yes
No
Yes
No
If you do plan to travel, please provide more information:
Do you have health insurance?
If Yes, what is the name of your health insurer? ___________________________________________________
Are you a veteran of U.S. Armed Forces:
Yes
No
Are you a male who lived in the U.S. at any time between your 18th and 26th birthdays?
Yes
No
11
Are you registered for Selective Service?
Yes
No
(If you are a male between 18 and 25 years old, go to the selective service website https://www.sss.gov/default.htm to complete
registration form. Selective Service registration is required in order to be eligible to receive federal financial aid.)
Have you ever been convicted of or pleaded guilty to a criminal offense? (You will be required to complete a Criminal
Offender Record Inquiry (CORI) for health care college programs/careers.)
Yes No
Do you have a CORI (Criminal Offense Record Inquiry)?
Yes
No
Do you have a disability?
Yes
No
If yes, are there any accommodations that you require?______________________________________________
FINANCIAL AID:
Have you completed the FAFSA (Free Application for Federal Student Aid) form?
Yes No
When did you apply? _______________________
Have you ever received Financial Aid?
Yes
No
Have you filed taxes for previous year?
Yes
No
When?__________________________________
How do you intend to pay for college? _________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
What percentage of loans would you be comfortable taking to pay your total tuition cost (if you did not qualify for
free financial aid (federal grant money, state grant money) or receive scholarships?
less than 10%
25%
50%
Do you owe money from a previous school loan?
75%
Yes
100%
No
If Yes, how much? $__________________
12
COMPUTER SKILLS:
1) I have a computer at home.
Yes
No
2) I have access to the internet.
Yes
No
3) I have a printer at home.
Yes
No
4) My computer skills are
Poor
Fair
5) I use a computer regularly in my job.
Yes
No
Good
Excellent
How often do you check your e-mail account? ______________________________________________
College planning:
I prefer to attend a college program (check all that apply):
During the day (before 4pm)
Evenings (after 4pm)
On weekends
When I start college, I would most like to (please check one):
Work full time and attend college full time
Work full time and attend college part time
Work part time and attend college full time
Work part time and attend college part time
When you begin college, would you consider working fewer hours so that you can focus on school?
Yes
No
Are you interested in enrolling in college while you attend Bridges to College?
Yes
No
Certification of Information
I certify that the information I have provided on this Bridges to College application is true and accurate. I
understand that any misrepresentation, omission or incorrect information may result in dismissal from the
Bridges to College Program at JVS.
Please sign and date
__________________________________________
Signature
___________________________________
Date
13
Bridges to College Schedule Assignment
Please write all of your weekly schedule commitments on the blank schedule. Include in
your schedule the following information:
Bridges to College Class schedule:
1. Academic Classes - 4 days per week (Monday – Thursday) from
9am to 12 noon
2. Coaching Class - 1 day per week (12:30 – 2pm)
3. Other classes/academic programs you are currently enrolled in - college, adult
learning programs, community organizations, etc)
4. Work Schedule (include your work schedule for all jobs)
5. Commute (expected commute time to work and JVS)
6. Family responsibilities
7. Regular weekly or monthly meetings and activities
8. Other time commitments (sleep, errands/house chores, time with family and friends,
religious worship/services, hobbies, gym/exercise, etc)
(please use sample schedule below as an example of how to complete the schedule)
Sample Schedule
6:00 –
7:00am
7:00 –
8:00am
8:00 –
9:00am
9:00 –
10:00am
10:00 –
11:00am
11:00 –
12:00pm
12:00 –
1:00pm
Sunday
Monday
Tuesday
Wednesday Thursday Friday
Saturday
Sleep
Sleep
Sleep
Sleep
Sleep
Sleep
Sleep
Breakfast/H
ouse
Chores
House
Chores
Services
Breakfast/ Get
Ready
Breakfast/
Get Ready
Breakfast/
Get Ready
Breakfast/
Get Ready
Sleep
Sleep
Commute
Commute
Commute
Commute
JVS English
Class
JVS English
Class
JVS English
Class
Commute
JVS Math
Class
JVS Math
Class
JVS Math
Class
JVS English
Class
JVS English
Class
JVS English
Class
Commute
JVS Math
Class
JVS Math
Class
JVS Math
Class
Library
Breakfast/
Get Ready
Work
Breakfast/
Get Ready
Gym
Work
Gym
Work
Work
Work
Work
Services
Family
Time
Family
Time
JVS
Coaching
Class
14
Sunday
Monday
Tuesday
Wednesday
Thursday
JVS
Class
JVS
Class
JVS
Class
JVS
Class
JVS
Class
JVS
Class
JVS
Class
JVS
Class
JVS
Class
JVS
Class
JVS
Class
JVS
Class
3:00- 4:00am
4:00 – 5:00am
5:00 – 6:00am
6:00 – 7:00am
7:00- 8:00am
8:00 – 9:00am
9:00 – 10:00am
10:00 – 11:00am
11:00am – 12pm
12:00 – 1:00pm
1:00- 2:00pm
2:00 – 3:00pm
3:00 – 4:00pm
4:00 – 5:00pm
5:00 – 6:00pm
6:00 – 7:00pm
7:00 – 8:00pm
8:00 – 9:00pm
9:00 – 10:00pm
10:00 – 11:00pm
11:00pm – 12am
12:00 – 1:00am
1:00 – 2:00am
2:00 – 3:00am
Friday
Saturday