Martin Luther King Jr., Family Services, Inc. Application for Admission 2015-2016
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| Springfield Clemente Course in the Humanities
in partnership with the Bard College Clemente Course hosted by Martin Luther King Jr., Family Services, Inc.
Please fill in the information below. If you have questions about this form, call the Clemente Course Site Coordinator at 413 746-3655. The application deadline is August 30, 2015. Be sure to complete the personal statement on the application or on an attached sheet. Mail or drop off your application to: Clemente Course Site Coordinator, Martin Luther King Jr., Family Services, 106 Wilbraham Rd., Springfield, MA 01109 Selected applicants will be contacted by the coordinator for an interview. Personal Information Name______________________________________________________________________________________ Date of birth ______________________________________Sex _________________ Month/day/year M/F/TG Home address _______________________________________________________________________________________ Number and Street, Apt. # City State Zip Code Mailing Address (if different) ________________________________________________________________________ Home phone ________________________ Work/other phone_______________________ E-mail ____________________ Emergency contact _________________________________________________________________________________ Name Phone Ethnic or racial heritage (optional) _______________________________ First language____________________________ U.S. Citizen __________ Permanent resident __________ Other status (please specify) ____________________________ 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? ____________ How did you hear about the Clemente Course _________________________________________________ _____________________________________________________________________________________________ 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) _____________________________________________________________________ What is your 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? (Specify) _____________________________________________________ What other jobs/training have you had? ___________________________________________________________________ Are you enrolled in other programs (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 Please use the space below to write your personal statement or attach a one-page typed document. Describe yourself, your interests, reasons for taking this course, plans for the future, and anything else you would like to tell us. The Clemente Course and Bard College do not discriminate in education, employment, admission, or services on the basis of sex, sexual orientation, race, color, religion, national origin, or handicapping conditions. Directory: uploads uploads -> 587 Return function, r i(X) r i(0) r i(1) r i(2) r i(3) 1 0 2 4 6 Thermal Station, I 2 0 1 5 6 3 0 3 5 6 10 uploads -> Department of science and humanities department of mathematics part-a questions and answers uploads -> The Case Against the nypd’s Quota-Driven ‘Broken Windows’ Policing What Is It? uploads -> For want of a nail uploads -> Ownership Models There are two different types of ownership models uploads -> Police Militarization uploads -> City of rising star regular meting thursday, july 14, 2016 uploads -> Township of winfield uploads -> Stop Militarizing Law Enforcement Act of 2014 uploads -> The Black Panther Party’s Ten-Point Program What We Want Now! Download 19.17 Kb. Share with your friends:
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