MiraCosta College
Bridges to the Future Program
Application Form
Full Name (First, MI, Last): _________________________________Gender: _________DOB_________________
Address: _____________________________________________________________________________________
City, State & Zip Code: __________________________________________________________________________
E-mail address: _________________________________Phone number(s) include area code:
Date started college (MM/DD/YY):
Major: ___________________________________
Do you plan to obtain an AA degree before transfer? (Y/N):___ College GPA: _______________
Anticipated 4-yr institution: _________________
Desired ultimate degree (circle one): Associates
Doctorate
Combined M.D./PhD
Anticipated Major at 4-yr inst: ___________
Baccalaureate
Masters
Research Doctorate
Clinical
Other professional degree
Anticipated transfer date __________High School from which you graduated:
Are you legally eligible for employment in the United States?* (Y/N):___
Are you a citizen or a non-citizen national?* (Y/N):___ Student ID #: ________________________
*
If accepted to the program you will be required to submit proof of your legal right to work in the United States. In addition, the Bridges program
requires that participating students be either citizens or non-citizen nationals. If you do not fit either of these two classifications, you will be unable to
participate in the program.
Please check the box that best describes your ethnicity.
White (non-Hispanic)
Chinese
Japanese
Korean
Laotian
Cambodian
Vietnamese
Asian Indian
Other Asian
Black (non-Hispanic)
Mexican
Mexican-American, Chicano
Central American
South American
Other Hispanic
American Indian,Alaskan Native
Thai
Guamanian
Puerto Rican
Hawaiian
Samoan
Other Pacific Islander
Filipino
Cuban
Other non-white
Decline to state
Please attach the following materials: APPLICATION DEADLINE EACH YEAR: JULY 31
1. Unofficial transcripts to confirm good academic standing
2. Personal statement, including career aspirations
3. Two letters of recommendation. At least one letter must address your strength as an applicant for this program;
at least one letter must be from a science teacher.
To the best of my knowledge, the information I am supplying is accurate.
______________________
Printed Name
Return completed application to:
______________________________
Signature
________
Date
Denise Stillinger, Bridges Coordinator
MiraCosta College, San Elijo Campus
3333 Manchester Ave.
Cardiff-by-the-Sea, CA 92007
Applications can also be sent via intercampus mail to Denise Stillinger, mail station 17A.
Direct questions to: Denise Stillinger (760) 757-2121 ext. 8030 or dstillinger@miracosta.edu
Fn=106739768
Rev Aug 03