The Bard College Clemente Course in the Humanities At Elm Park Community School, Worcester, ma



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The Bard College Clemente Course in the Humanities

At Elm Park Community School, Worcester, MA

Hosted by Worcester Interfaith


Application for Admission
To apply: 1) Call Elizabeth Bacon at 774-276-1166 to schedule an interview. All interviews will take place at Worcester Interfaith, 111 Park Ave., Worcester, MA 01609 (First Baptist Church)

2) Please fill out this application completely and bring it with you to the interview.
Personal Information
Legal name______________________________________________________________________________________
Date of birth ______________________________________Sex _________________

month/day/year M/F


Home address _______________________________________________________________________________________

Number and street, Apt. # city state zip code


Mailing Address (if different)___________________________________________________________________________
Home phone ________________________ Work/other phone_______________________ e-mail____________________
In emergency contact _________________________________________________________________________________

Name Phone


Ethnic or racial heritage (optional) _______________________________First language____________________________
U.S. Citizen __________ Permanent resident __________ Other status (please specify)____________________________
Entitlements (SSI, WIC, TANF, AFDC etc.) ______________________________________________________________
Education
Highest grade completed __________Are you currently in school?___________ Where?____________________________
Did you graduate from high school? __________ When?__________ Name of School______________________________
Are you a GED recipient? _______ Date of GED completion _______Are you currently working toward a GED? ________
Have you ever attended college?_________ Where? _________________________________For how long? ___________
Have you earned college credits? ________ How many? __________________ Why did you leave college? ____________
___________________________________________________________________________________________________
Family/ Household

Marital status: ◊ single ◊ married ◊ separated ◊ divorced ◊ widowed


Do you have children? ____________ If yes, what are their ages? __________________ Do they live with you?_________
With whom do you live? ◊ alone ◊ with parents ◊ with spouse or companion ◊ with siblings ◊ with friends
◊ other arrangement (please specify) _____________________________________________________________________

(OVER)


What is you annual household income (before taxes)? ◊ under $1,000 ◊ $1,000 - $5,000 ◊ $5,000 - $10,000
◊ $10,001 - $15,000 ◊ $15,001 - $20,000 ◊ $20,001 - $25,000 ◊ $25,001 -$30,000 ◊ Over $30,000
Employment/Training
Skill/occupation _____________________________________________________________________________________
◊ employed full time ◊ employed part-time ◊ unemployed ◊ intern ◊ volunteer
Are you currently in a training program? (please specify)_____________________________________________________
What other jobs/training have you had? ___________________________________________________________________
Are you enrolled in other programs (please specify: recovery, therapy, etc.)_______________________________________
Childcare/Transportation
Will you need childcare to attend these classes? If yes, please specify ages of children______________________________
Will you need bus fare to attend classes? _________ If yes, describe cost per class: ________________________________
___________________________________________________________________________________________________
Personal Statement
In the space below, write a statement describing yourself, your interests, your reasons for wanting to take this course and your plans for the future. (c 250 words or more)

Bard College does not discriminate in education, employment, admission, or services on the basis of



sex, sexual orientation, race, color, religion, national origin, or handicapping conditions.

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