Cohort Year:
Golden West College
Program Registration Form
WEBAPP
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Personal Information
GWC Student ID: __C__________________________
Name: ________________________________ _____________________________ Gender:  Male Female
(Last)
(First)
Address: ___________________________________ City: __________________________ Zip Code: __________
Phone Number: (______)______________________ Alternate Phone: (______)______________________________
Email Address: _______________________________________________________________________________
Age:  under 18  18 – 25
Ethnicity (Optional):
 26-35
 36+
Date of Birth_______________________
 African-American
 Asian / Vietnamese
 Central/South American/Latino
 Mexican/Mexican-American/Chicano
 White/Caucasian
 Native American
 Pacific Islander / Filipino
 Other: Indicate___________________
High School Attended: _________________________________________ Graduate?  Yes: Year: _______  No
Academic Information
Have you attended other colleges?  No  Yes: Campus(es): _______________________ # of Units: _________
Units Completed:
 0 – 15
 16 – 30
 31 – 45
 46 – 60
 60 +
Overall GPA:
 None
 0.0 – 1.9
 2.0 – 2.5
 2.6 – 3.0
 3.1 – 3.6
 3.6 – 4.0
GWC English Placement
 English G098 (G009)
 English G099 (G010)
 Other: ____________________
 English G100
GWC Math Placement
 Math G008
 Math G010
 Math G030
Other: ________________________________________
Are you eligible for financial aid?
Planning to Transfer?
 UC
 ESL G071
 Math G100 – G160  Math G170 or higher
 Yes
 No
 Don’t Know
 CSU
 Private
 Undecided
 AB540
Transfer Choice:
Campus
1) ________________________ 2) _______________________ 3) ________________________
Major: ______________________________________________________________________
Services
Which other campus programs are you part of?
 EOP/S
 CARE
 Teach3
 Athletics
 DSPS
 CalWorks/Re-Entry
What services are you interested in? (Check all that apply)
 CSU Transfer
 Financial Aid / Scholarships  Career Exploration
 UC Transfer
 Tutoring Students
 Ethnic/Cultural Events
 Major Selection
 Campus Services
 Other: __________________________________
Are you currently employed
Number of Hours per Week
 Yes  No
If yes, Position: ___________________________________
 0 – 10  11 – 16  17 – 24  25 – 32  33 – 40 40 +
Continued on back
Signature
Commitment
Personal Statement
Please indicate why you want to be in the Puente Program at GWC:
Intent to Register
I agree to make a full commitment to the Puente Program at Golden West College. This commitment
includes the following:
 Enroll in the two-course English writing class sequence: English G099 (G010) in the Fall and English
G100 in the Spring semester. (One-year commitment)
 Enroll in the paired Student Success courses: College G100 in the Fall, and Counseling G104 in the
Spring semester.
 Attend all class sessions regularly
 Participate in all off-campus activities, such as campus tours and conferences
 Participate in mentoring activities
 Participate in occasional evening and Saturday program activities
 With the assistance of the Puente Counselor, Complete a Student Education Plan for completing AA
Degree and university transfer requirements.
I authorize the Puente Program to release my name, address, ethnicity, and image to campus programs at
Golden West College and other universities for educational purposes only.
*I promise to participate in all related Puente Program activities and enroll in required courses each semester *
Signature: _______________________________________________________ Date: _______________________
Please return form to: Nancy Fong, Puente Counselor
GWC Counseling Division, 15744 Golden West Blvd, Huntington Beach, CA 92647
Administrative Use
Administrative Use Only: Please do not write in this area
Form Received:
Date: __________________________________________
Attended Orientation:  Yes Date: ________________________
 No
Counselor / Instructor Interview:
 Yes Date: ________________________
 No
Entered in Database:  Date: ___________________ by: _________________________
ID: _____________
Matched with mentor:  Date: ___________________ Mentor Number: ___________________________
SEP Completed:
 Yes  No Date: __________________
File Established:  Yes  No
Participation:
 Attended Conference
 Campus Tour (Location): __________________
Referred by:  Counselor  Instructor/COUN Course  TC  Flier/Ad  Friend Walk-in  Other