Application 2014
PLEASE COMPLETE ALL ITEMS AND PRINT CLEARLY
What U C L A Bridges can do for you:
 Provide advising and counseling on research careers and opportunities
 Provide professional development seminars, workshops and tutoring in math, science, and engineering to meet your
needs
 Assist you with applications for summer programs and admission to 4-year universities
 Assist you with obtaining summer, part-time, or full-time research opportunities
 Assist you with all transfer requirements to a 4-year university
 Assist you with the application process for internships and summer enrichment programs
What we need you to do: (please initial next to each item)
 Understand the importance of getting involved in student organizations for your academic and professional
career development
 Attend all Bridges events throughout the calendar year to increase your competitiveness in STEM
o 2014-2015 Events
 Panel at Pierce: 8:30-1:00 pm on October 10th and February 13th,
 Location LAPC, Rooms TBA
 Bridges to UCLA Day: 8:00 – 2:00 pm on November 8th, April 18th and end of July (TBA),
Location UCLA, Rooms TBA
 Enroll in PBS seminars and Bio40 or its equivalent
 Understand that pursuing a degree in math, science, and engineering requires your education to be your number one
priority
 Work towards fulfilling the core requirements needed by your major to transfer to a four year university
 Commit to continue working in developing good study habits by attending Bridges’ workshops, tutoring, etc., in order
to improve and/or maintain your GPA
 Submit 6th and 12th week progress reports to your Bridges Coordinator by due date.
 Submit a copy of your unofficial transcripts at the end of each semester to your Bridges Coordinator
 Submit a copy of an updated Counselor Educational Plan each Fall
 Apply to summer research programs
 Complete all surveys administered by your Bridges Program and Cobblestone Applied Research and Evaluation Inc.
INSTRUCTIONS
Complete the application form as thoroughly as possible and return it signed to the UCLA Bridges Coordinator on
your campus.
You must also submit:
 Copy of your unofficial college transcripts (including ALL schools attended)
 Copy of your student ID clearly showing your picture and name (suggested size, zoomed in 200% in a
photocopy machine)
 Statement of Intent: (750-1000 word maximum, please include the word count at the bottom of your essay).
Your statement should address the following:
a. What is your major and what are your career goals?
b. Why do you want to do research?
c. What will you gain and what do you plan to bring to this experience if selected?
Applications are considered incomplete until all of the above materials are submitted as well as the signed
application. Return in person to your Grant Coordinator Alina Saroukhanian or via email to sarouka@lavc.edu
Personal Information
Revised 8-22-14
Application 2014
PLEASE COMPLETE ALL ITEMS AND PRINT CLEARLY
Today’s Date
Campus/Student ID #
First Name:
Middle (or initial):
Last Name:
Permanent Address:
Current Address/Mailing Address (if different):
City:
State:
Home Phone: (
)
Work Phone: (
)
Permanent E-mail:
Gender:
Male
Zip:
Cell Phone (
Birth date:
/
)
/
Female
Ethnicity Please check the box that most accurately describes your ethnicity:
 Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin)
 American Indian or Alaska Native (A person having origins in any of the original peoples of North, Central, or South America, and who
maintains tribal affiliations or community attachment.)
 Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
 Black or African American (A person having origins in any of the black racial groups of Africa.)
 Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other
Pacific Islands.)
 White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
 Other : please explain
If you are American Indian or Alaskan Native, what is your Tribal Affiliation
Is a language other than English spoken regularly in your home?
No
Yes
If yes, specify
Courses currently enrolled in?
Residential status?
 US Citizen
 Permanent Resident
 F1 Visa
 Resident Alien
Previous school(s) attended:
High School:
Date:
College:
Dates:
College:
Dates:
Semester and year first enrolled at this
college:
/
Semester / Year
What is your declared / intended major? __________________________________________
What is your degree objective?
BS
MS
PhD
MD/PhD
MD
Pharm.
DDS
Are you a first generation college student?
Yes
No
Are you in EOP&S?
Yes
No
Do you receive Financial Aid?
Yes
No
Are you AB-540?
Yes
No
Total number of college units completed:
0-29
30-60
60+
Current college GPA:
Cumulative College GPA:___________
College Counselor:
Highest level of college math passed?
Revised 8-22-14
Intended Intended
Transfer College(s):
Transfer College(s):
1.
1.
2.
2.
3.
4.
5.
Prospective date of transfer:
/
Semester Year
Other__________________
Obstacles that may interfere with your
education? (check all that apply):

Employment issues

Family obligations

Knowledge of educational system

Exceptional needs (specify below)
Application 2014
PLEASE COMPLETE ALL ITEMS AND PRINT CLEARLY
Are you employed? __ Yes __No
If yes, how many hours per week? ___
If yes, who is your employer? ___________________________
What type of work have your parents or guardians typically done over
the past years or prior to retiring? (Please indicate by using a letter)
What is the highest level of education achieved by each of your
parents/guardians? (Please indicate by using a letter)
Father
Father
Mother
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
A. No school/elementary school
B. 8th grade or less
C. Some high school
D. High School graduate
E. Some college/university
F. Community college degree
G. 4-year college degree
H. Professional degree (law, medical, etc)
I. MS/MA/MBA/Ph.D
J. Other
K. Don’t know
Mother
Never Employed
Farm Worker
Business Administration
Retail/Sales/Clerical
Mechanic
Professional – (Doctor, Lawyer, Other Professional)
Factory Worker
General Laborer
Teacher/Professor
Skilled technician – Medical, Educational, Trades
Engineer/Computer Scientist/Scientist
Other
Don’t know
I certify that the information I provided above, in the application and the submitted materials are true and correct to
the best of my knowledge.
_________________________________
Print full name
_________________________________
Sign name
____________________________
Date
If you are determined eligible for the UCLA Bridges to the Baccalaureate Program, you are agreeing to follow the student
contract on the next page. Please read the contract thoroughly, in order to fully understand what is expected of you
as an active Bridges student.
The goal of the Bridges Program is for participants to matriculate as a biomedical science major to UCLA and/or any 4year college or university. While participation in the program DOES NOT guarantee admission to the Bridges Summer
Undergraduate Research Program (BriSURP) or into UCLA, participation in the program and adhering to contract
requirements will increase your eligibility for consideration and prepare you to be a competitive applicant for transfer to
UCLA and/or other 4-year colleges or universities
Revised 8-22-14
Bridges Student Contract
If you are determined eligible for the UCLA Bridges to the Baccalaureate Program, you are agreeing to follow
the student contract below. Please read the contract thoroughly, in order to fully understand what is
expected of you as an active Bridges student.
Admissions Agreement/Personal Information Release: (please initial next to each line)
___ I agree to work with the Bridges Program and my Community College Counselor towards creating and following an educational
plan that will allow me to transfer to a four year university in my declared major.
___ I will submit an updated educational plan every Fall to my Bridges Program Coordinator.
___ I will notify my Bridges program coordinator of my class schedule each semester.
___ I will notify Bridges if I fall below a 2.0 grade point average or drop below12 units/semester.
___ I will complete 6th and 12th week progress reports each semester and return to my Bridges coordinator by the following Friday.
___ I understand that to continue to Year 2 of the Bridges to UCLA Program, I must have a GPA of 3.0 or higher.
___ I will seek academic counseling advise from the Bridges Administrator and TAP counselor at LAVC/LAPC every semester
during my second year as a Bridges participant.
___ I will participate in Academic Excellence Workshops and or tutoring offered for the classes I take.
___ I agree to work towards meeting the eligibility requirements for UCLA for my science major.
___ I agree to enroll in PBS II at LAVC and Bio40 offered at LAVC or its equivalent offered at ELAC, if I have not already taken Bio
110 at my community college.
___ I agree to attend all PBS I seminars and activities at (insert your CC and dates offered).
___ I agree to attend 3 Bridges to UCLA events at UCLA Campus.
2014-2015 events are 8am – 2pm on November 8th, April 18th and end of July date TBA
___ I agree to attend all Bridges Panels at Pierce activities at Pierce College.
2014-2015 events are 8:30 am – 1 pm on October 10th and February 13th
___ I agree to serve as a supplemental instructor for Chem 60, Chem 101, or a Biology Lab as requested through the Bridges Program.
___ I agree to apply to a Summer Research Experience for Undergraduates and inform my Bridges Program Coordinator of the
programs I applied to and if I am accepted.
___ If I matriculate to UCLA or any other 4-year university, I will apply for the Bridges to the Baccalaureate Summer Undergraduate
Research Program (BriSURP) at UCLA the summer before I transfer.
___ I understand that participation in Bridges does not guarantee admission to Bridges Summer Undergraduate Research Program
(BriSURP).
___When I matriculate to UCLA or any other 4-year university, I will notify my Bridges Program Representative of what institution I
will be transferring to and what my declared major will be.
___ The Bridges to UCLA Program is funded by the National Institutes of Health/National Institute of General Medical Sciences
(NIH/NIGMS, Grant #GM050067, P.I. Simmons). As required by the NIH, I agree to be tracked for at least 10 years following
completion of the program. I will communicate with the Bridges Administration at UCLA (bridges@lifesci.ucla.edu) yearly to
give updates on my academic status, employment and contact information as necessary.
___ Cobblestone Applied Research and Evaluation, Inc. evaluates the UCLA Bridges to the Baccalaureate Program. I agree to fill out
all event-related and online surveys, and participate in focus groups as requested.
___ I agree to let my community college release any data pertaining to my academic performance and progress to the Bridges Program and
Cobblestone Applied Research and Evaluation Inc.
___ I will notify Bridges of any changes in my name, address, or phone number.
___ I understand that I will be held to a high standard of ethics, behavior and commitment to the goals of the Bridges Program
___ If I fail to meet my responsibilities as outlined above, I understand that I may be disqualified as a Bridges participant
I give my permission for Bridges to give my name, phone number and address to college and employer representatives, and to use
my photograph in Bridges and college promotional materials.
____Yes ____No
By signing below, I understand that I give my full permission for Bridges to obtain my transcripts and information about
my performance from colleges I attended, testing agencies, financial aid and other offices to determine my continued
eligibility for the Bridges Academic program and for reporting purposes. You may be asked to provide additional
information for eligibility determination.
I certify that I have provided true and correct information.
Applicant Signature
Date
Parent/Guardian Signature if under 18
years old
Director Signature
Revised 8-21-14
Date
Date