NASC Summer Bridge Application
Name
*
First Name
Middle Initial
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about the summer program?
*
How did you hear about the summer program?
Please Select
High School Counselor
CCC Staff or Instructor
Social Media
Flyer on Campus
Other
If other, please specify.
Which campus would you like to attend?
*
Lone Tree Campus, Flagstaff, AZ
Page Center, Page, Arizona
Tribal Affiliation
*
What tribe are you affiliated with?
*
Please Select
Navajo
Hopi
Apache
Zuni
Hualapai
Havasupai
Other
If other, please specify.
Gender
*
Male
Female
Prefer not to respond
Education
*
I am currently a senior in high school
I have my high school diploma
I have my GED
I have some college experience
I am a current CCC student (preference will be given to new college students)
Education:
*
I am currently a senior in high school
I have my high school diploma
I have my GED
I have some college experience
I 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 courses
I have taken dual enrollment and/or CAVIAT courses
I have some college experience from another school
I 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 courses
I have taken dual enrollment and/or CAVIAT courses
I have some college experience from another school
I am a current CCC student (Preference will be given to new college students)
High School Name
*
High School GPA
*
Date GED Completed
*
-
Month
-
Day
Year
Date
Have you applied for Financial Aid (FAFSA)?
*
Yes
No
Have you applied for any scholarships?
*
Yes
No
Statement of Agreement and Consent
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
*
Submit
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