MCCP
CBC
HCC
SCCC
CAMPUS:
 ECC 
 OC

 YVCC 
WASHINGTON
MESA Community College Program (MCCP) Application
PLEASE COMPLETE ALL ITEMS
CONTACT INFORMATION
Student ID:
(#########)
Social Security No.:
(###-##-####)
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Primary Email:
Primary Phone:
WA
Zip:
((###) ###-####)
ACADEMIC INFORMATION
Previous school(s) attended:
High school:
Running Start:
College:
Degree:
College:
Degree:
Dates:
No
No
No
(yyyy to yyyy)
Intended major:
Yes
Yes (Degree
Yes (Degree
Date first enrolled at this college:
to
Dates:
to
(yyyy)
(yyyy to yyyy) Projected transfer date: <Quarter> /
Intended transfer college(s): (In order of preference)
Dates:
to
(yyyy to yyyy)
)
)
<Quarter> /
(yyyy)
Obstacles that may interfere with your education
(Check all that apply)
Current college advisor/counselor:
Highest level of college math passed:
<Select from list>
Financial need
Employment issues
Family obligations
Knowledge of educational system
Transportation/ travel distance
Exceptional needs (Please specify:
)
Courses currently enrolled in:
Total college credits completed:
Intended two-year transfer degree track:
<Select from list>
<Select from list>
Are you employed?
Current college GPA:
No
Yes (Hrs/wk
)
DEMOGRAPHIC INFORMATION
Birth Date:
Gender:
Ethnicity:
(mm/dd/yyyy)
Resident
Status:
<Select from list>
American Indian/Alaskan Native (Tribal affiliation
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Native Hawaiian/Pacific Islander
Multiracial (If multiracial, select all that apply.)
)
U.S. Citizen
Permanent Resident
F1 Visa
Resident Alien
Is a language other than English spoken
regularly in your home?
No
Yes (Language
Are you a U.S. Veteran?
What is the highest level of education achieved
by each of your parents/guardians?
Father
Mother
<Select from list>
<Select from list>
What type of work did or does each of your
parents/guardians typically perform?
Father
Mother
<Select from list>
<Select from list>
)
No
Yes
Please continue to next page.
MCCP CAMPUS:
CBC  ECC 
HCC
OC

SCCC  YVCC 
WASHINGTON
MESA Community College Program (MCCP)
STUDENT CONTRACT
If you are determined eligible for the MESA Program, you are agreeing to follow the student contract below. FULFILLMENT OF THE
STUDENT CONTRACT IS PART OF YOUR ELIGIBILITY REQUIREMENT FOR PARTICIPATION IN THE MESA COMMUNITY COLLEGE
PROGRAM. This Student Contract is intended to help you get the most out the available MESA services, while helping to develop your
academic and professional skills. Please read the contract carefully, in order to fully understand what will be expected of you as an active
MESA student.
Your Commitment to MESA
MESA’s Commitment to You
As a student participant in Olympic College (OC) MESA,
I will:
 Participate in the OC MESA Orientation.
 Make education my number one priority.
 Follow the suggested educational plan designed by
MESA/OC Advisors.
 Participate in available Academic Excellence
Workshops for the classes I take.
 Utilize on-campus tutoring services, as required.
 Maintain an overall GPA of at least a 2.50.
 Meet with the OC MESA Director at the end of each
quarter or when class changes occur.
 Notify the OC MESA Director of any changes in my
name, address, or phone number.
 Actively participate in industry–based activities
(presentations, field trips, job fairs, etc.).
 Assist in recruiting other eligible students to OC
MESA.
 Be respectful and supportive of other OC MESA
students.
In return, OC MESA will:
 Encourage essential skills for academic/professional success through
focused student orientation.
 Provide collaborative learning techniques in weekly Academic
Excellence Workshops to encourage mastery of key STEM concepts.
 Provide access to tutoring services.
 Provide access to select textbooks and equipment (e.g., computers,
calculators) to support academic success.
 Ensure four-year university transfer requirements are met.
 Provide opportunities to visit four-year university campuses.
 Integrate academics and intended careers through industry participation
in design competitions, field trips, mentorship, internships, and other.
 Assist in identifying and securing internships and summer
enrichment programs.
 Offer financial assistance (scholarships/stipends) to qualified students.
 Assist in identifying/securing external scholarships and fellowships.
 Provide an OC MESA webpage/social media outlet for information
exchange.
 Provide a dedicated MESA Center that supports a program of activities
and allows students to study, access computers, and socialize.
 Offer supportive communities to encourage student success and
leadership.
 Recognize student accomplishments.
Authorization and Liability
I give my permission for the MESA Director and designated staff to use my photograph and/or quotes for MESA
related press releases, information and media material, especially in promoting my success and achievements.
I understand that my refusal will not impact my eligibility and that I may later withdraw my consent in writing.
No
Yes
By applying to the MESA Community College Program (MCCP), I understand that I give my permission to obtain information about my
academic performance from colleges and testing agencies, financial aid and other offices to determine eligibility for the MCCP and data
research. This information will not be reported to any agency in a way that would identify the student. I may be asked to provide additional
information for eligibility determination. I further understand that if eligible, my academic information will be used for reporting and grant
purposes, scholarship disbursement, academic tracking, and otherwise account of my performance. I certify that I have provided true and
correct information.
Applicant Signature/If under 18 years of age, Signature of Parent/Guardian
(Type name for electronic signature)
______________________________________________
MCCP Director Signature
3/12/2016
Date
_________________________
Date
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