Springfield Clemente Course in the Humanities
in partnership with the Bard College Clemente Course
hosted by Martin Luther King Jr., Family Services, Inc.
Application for Admission 2015-2016
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.
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