NASC Summer Bridge Application

Name*

First NameMiddle InitialLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about the summer program?*

How did you hear about the summer program?

If other, please specify.

Which campus would you like to attend?*

Lone Tree Campus, Flagstaff, AZPage Center, Page, Arizona

Tribal Affiliation*

What tribe are you affiliated with?*

If other, please specify.

Gender*

MaleFemalePrefer not to respond

Education*

I am currently a senior in high schoolI have my high school diplomaI have my GEDI have some college experienceI am a current CCC student (preference will be given to new college students)

Education:*

I am currently a senior in high schoolI have my high school diplomaI have my GEDI have some college experienceI am a current CCC student (Preference will be given to new college students)

What is your current status?*

I have never taken any college level coursesI have taken dual enrollment and/or CAVIAT coursesI have some college experience from another schoolI am a current CCC student (Preference will be given to new college students)

What is your current status?

I have never taken any college level coursesI have taken dual enrollment and/or CAVIAT coursesI have some college experience from another schoolI am a current CCC student (Preference will be given to new college students)

High School Name*

High School GPA*

Date GED Completed*

Date

Have you applied for Financial Aid (FAFSA)?*

YesNo

Have you applied for any scholarships?*

YesNo

Agreement 1*

I understand that I will need to apply to CCC (this will require submission of high school transcripts and identification) and complete the courses offered under the Summer Bridge program.

Agreement 2*

I understand that I will be participating in a new student orientation.

Agreement 3*

I understand that I will be meeting with my assigned advisor to register for courses for the Summer Bridge Program and meet at least twice during the summer.

Agreement 4*

I understand that I will be meeting with my assigned peer mentor at least two times during the summer.

Agreement 5*

I understand the Summer Bridge program is funded by the U.S. Department of Education. All information is strictly confidential and is used solely for the purpose of determining eligibility of students applying for participation. All applications are accepted for review regardless of race, color, national origin, religion, gender, or disability (U.S. Dept. of Education-GEPA Section 427)

Agreement 6*

I hereby authorize the Summer Bridge program to obtain, copy, review and discuss my student records with the appropriate CCC staff, faculty and college departments a pertinent to my participation in the program. I also give my permission to be interviewed and/or photographed by program staff for use of marketing/advertising.

I agree to the agreement and consent statement above*

NASC Summer Bridge Application

Statement of Agreement and Consent