BRIDGES TO THE BACCALAUREATE
APPLICATION FORM
UNIVERSITY OF MASS BOSTON IN PARTNERSHIP WITH BUNKER HILL AND ROXBURY COMMUNITY
COLLEGES
DATE FORM FILLED OUT: ______/______/_______
BACKGROUND INFORMATION
Your name: _______________________________________
Date of Birth: _____/_____/______
College or University: ___________________________________
College ID # ________________________
Gender:
Citizenship or status:
Male
USA
Female
Permanent Resident
Other
To which Race/Ethnicity group(s) do you belong? Choose all that apply:
Black/African American
Asian American
(Japan, China, India, etc.)
Latino/a (Puerto Rican, Mexican, etc)
Pacific Islander
(Hawaiian, etc.)
Native American/Alaskan Native
Other
(Specify)
White/Caucasian (Non-Hispanic)
I will be a first generation college graduate. Yes
_______________________
or No
What is the highest degree received by your parents or legal guardian?
Father
Mother
Legal Guardian
---------------------------------------------------------------------------------------------------------------------Some High School
High School Diploma
2-Year College Degree
4-Year Baccalaureate Degree
Masters Degree (MS, MBA, etc.)
Doctorate or Other Terminal Degree
CONTACT INFORMATION
Local Residential Address: _________________________________________________________
City: _______________________________ State: ____________
Home Phone Number: (_____) _____-______
Zip Code: ____________
Cellular Phone Number: (_____) _____-______
Personal Email Address: ________________________
College Email Address:
________________________
Emergency Contact Name and Address: ___________________________________________________________
ACADEMIC INFOR MATION
SAT Total _____
Quantitative _____
Verbal _____
ACT Total _____
Quantitative _____
Verbal _____
High School _________________________________________
Have you taken Advanced Placement (AP) courses? Yes
HS GPA _______
HS % Class Rank ____
No
Have you participated in any other pre-college programs affiliated with a college? Please name them all.
1.
__________________________________________
2.
__________________________________________
3.
__________________________________________
What is your current academic major in college? _____________________________________
How many college credits have you completed as of the date of this form you are filling out? ___________
Have you taken Calculus in college yet? ______
What 4-year bachelor’s degree would you like to pursue. ____________________________
Please list all of your college courses by full name for your present term and for next term:
Courses you are taking this current term (list department, course number, and title):
__________________________________
___________________________________
__________________________________
___________________________________
__________________________________
___________________________________
Courses you plan to take next term:
__________________________________
___________________________________
__________________________________
___________________________________
__________________________________
___________________________________
LEADERSHIP INFORMATI ON
Please list any honors or awards received including honor societies:
_________________________________ _____________________________ __________________
_________________________________ _____________________________ __________________
_________________________________ _____________________________ __________________
Please list extracurricular and community activities:
_________________________________ _____________________________ __________________
_________________________________ _____________________________ __________________
_________________________________ _____________________________ __________________
CAREER INTERESTS – CHECK ALL THAT APPLY
Applied Mathematics
Highest degree that you plan to obtain:
Biology
BS/BA
Biochemistry
MS
Biomedical Research
Ph.D
Bioinformatics
MD
Cancer Research
DDS
Cell & Molecular Biology
Chemistry
Other
(Specify) _______________________
Computer Science
Environmental Science
Genetics
Mathematics/Statistics
Medical/Dental/Veterinary
Microbiology
Neurobiology
Nursing/Health Science
Physics
Plant Sciences
Other _______________
SCIENCE, TECHNOLOGY, ENGINEERING AND MATH (STEM) ACCELERATION ACTIVITIES OF INTEREST
STEM Career Seminars
STEM Part-time jobs
STEM Mentors
STEM Summer Academic Programs
STEM Research Coaches
STEM Summer Non-Research Jobs
Adv Math Workshops
Local Industry Lab Visits
Research Skills Workshops
STEM Outreach Tutoring – K12
List any others
____________________________________________________
LAB PLACEMENT, LEADERSHIP ESSAY SECTION
1.
Of the career areas listed on previous page, which one for a research lab placement is your
a.
first choice:
b.
second choice:
c.
third choice:
2.
What activities (high school, community college, extracurricular, and work-related) do you feel provided you with leadership
experience? For each, explain how. (continue on back if you need more space)
3.
What specific areas of biology/chemistry/biomedical science interest you and why? (Your response will help guide the
coordinators of the Bridges Program with your placement in a research laboratory, so be specific as possible.)
4.
What courses, experiences, and/or people most influenced you to pursue a science degree? (continue on back if you need more
space)
PARENT OR STUDENT (IF OVER 17 YEARS OF A GE) SIGNED PERMISSION SHEET
I give (my or name of underage student) ___________________________________ permission to participate in the University
of Massachusetts Boston programs indicated on this form. I understand that participation in good standing includes attendance
at all sessions of activities outlined in program descriptions, and that there may be other expectations involving job shadowing
with professionals in a STEM field, off-site research trips and internships, and occasional group events. I give permission for
travel to any of these activities through the use of any transportation approved by UMass Boston. The University of
Massachusetts Boston is given permission to reproduce for publications any photos taken of this applicant at any program
activity.
I also consent to the disclosure of student information records maintained by high school or by my college or university to an
authorized representative of UMass Boston. This information will be maintained in a confidential manner and will be used only
for the purposes of evaluation and program improvement. Use is consistent with the Federal Family Educational Rights and
Privacy Act of 1974, or other state or federal laws, regulations, or policies. I understand that this permission may be withdrawn
at any time with written notification.
_______________________________________
Date:
_________________________
Parent/Guardian Signature for underage Student
In addition to permissions above, I certify that the information submitted in this application is complete and true to the best of
my knowledge.
______________________________________
Date:
_________________________
Student’s Signature
Please return this registration/application to:
Andrella King at Roxbury Community College