TheSTEMSummer BridgeApplication

Pleasefillouttothebestofyourability. Returncompleteapplicationto:

In Person:MarlaDresch,LS114(leaveinenvelopeoutsidetheindoorofficedoor if I’m not there) or Diana Gonzalez, MA111, (408) 852-2844

Mail:GavilanCollege

5055SantaTeresaBlvd.Gilroy,CA95020

ATTN:MarlaDresch,DepartmentofNaturalSciences

On line: Go to

EligibilityRequirements:Allapplicantsshallfillallofthebelowrequirements.Pleasecheckiftrue.

Iwillbeenrolledin10ormoreunitsatGavilanCollegeinthefallof2018

This will be my first time attending college.

Iam majoring or thinking about majoring in a calculus based STEM field

Personal Information

Name:______GavilanIDnumber: G00______FirstM.I. Last

MailingAddress:

______

CityStateZipPhone: home______cell______TextOK? __Yes__No

Preferred Email Address: ______Gender: (circle one) male female other:______Age:______

Ethnicity: Checktheboxoftheethnicgroupsyoumoststronglyidentifywith. (Checkallthatapply)

___African/AfricanAmerican/Black___Asian

___Hispanic/Latino___Filipino/FilipinoAmerican

___PacificIslander___EastIndian/Pakistani

___NativeAmerican___ White/Caucasian

___ Other: ______

Education

Are you currently a highschool student? Yes No

If yes, which highschool?______G.P.A.______

Ifno,do you have a high school diploma? Yes No If yes, indicate the highschool and the date the diploma was received:______GPA______

Whatisyoureducationalgoal? _____AAdegree_____AAdegreeplustransferTransferOnlyWhatisyourmajor?______

Ifundecided,whatisyourareaofinterest?______

Whatisyourcareergoal? Whattypeofjobdoyouseeyourselfdoingupongraduation?

______

______Whatarethebiggestchallengesyoufaceinachievingyoureducationalgoal?______

______

______

______Checkifyouareamemberof: ___TRIO ___MESA ___EOPS ___Puente

Whenareyouplanningtograduate/transferfromGavilanCollege?(Sem/Year)______

Iftransferring,whatareyourschoolsofinterest?______

______

PleaseprovideinformationaboutyourcompletedMath,Science,EngineeringandComputerSciencecourses. SciencecoursesincludeBiology,Ecology,Physics,Chemistry,otherPhysicalSciences,etc.

ClassTaken(Title) / School / Grade received / Sem/Yr.taken

Family Background

Theprimarylanguagespokeninthehomeofmychildhoodwas:______

Doyouhavechildren?___Yes ___NoIfYes,listages:______Areyouasingleparent? ___Yes ___No

Checkifyou: ___areaveteran ___havebeeninfostercare

Indicatethehighesteducationlevelofyourmother(leaveblankifunknown):

___SomeHighSchool ___HighSchoolGraduate ___SomeCollege___AssociatesDegree

___BachelorsDegree___MastersDegree___Doctorate(Ph.D.) ___OtherProfessionalDegree

Indicatethehighesteducationlevelofyourfather(leaveblankifunknown):

___SomeHighSchool___HighSchoolGraduate ___SomeCollege___AssociatesDegree

___BachelorsDegree___MastersDegree___Doctorate(Ph.D.) ___OtherProfessionalDegree

Financial Information

Doyoulivewithyourparents?YesNoIfyes:

Doyourparentsclaimyouasadependentontheirtaxreturn?YesNoDon’tknowTotalsizeofparent’shousehold(includingyourself):______

TotalHouseholdIncomeLastYear:______Ifno

Yearsyouhavelivedawayfromhome:_____ Numberofdependents(self,spouse,children):_____TotalHouseholdIncomeLastYear:______

ExtraCurricularInformation

Listanyotherschoolactivities,clubsorprogramsinwhichyouarecurrentlyparticipating.

______

Doyouhaveajob? YNIfyes,howmanyhoursaweek?______

Otherresponsibilities/activitiesoutsideofschoolandwork:______

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