Pathways Program Application

Section 1

First Name

Last Name

Email Address

Home Phone

Student Cell Phone

Mailing Address

Country

Street

City

Region

Postal Code

Sex

Female

Male

Birthdate

High School Graduation year

Were you born in the United States?

Yes

No

If not, where were you born?

Ethnicity

Hispanic

Non-Hispanic/Latino

If you are of African ancestry, list the countries or cultures of ancestral origin (e.g., Ghana, Liberia, etc.)

If you are of Asian ancestry, list the countries or cultures of ancestral origin (e.g., Chinese, Sri Lankan, etc.)

If you are of Caribbean ancestry, list the countries or cultures of ancestral origin (e.g., Jamaica, Haiti, etc.)

If you are of Hispanic ancestry, list the countries or cultures of ancestral origin (e.g., Mexican, Peruvian, etc.)

Student Academic Goals

Do you plan to go to college

Yes

No

Unsure

What is the highest level of education that you plan to complete? Please select only one choice.

High school diploma

Specialized training or certificate program: (such as Cosmetology license or Nurse’s Assistant certificate)

Two-year associate of arts or sciences degree:(such as AA, AAS, or AS from a community college)

Four-year Bachelor’s degree (such as BA or BS from a college or university)

Graduate School - Master’s degree (such as MA, MBA, or MS)

Graduate School - Doctoral or related degree (such as PhD, JD, MD, DVM)

Other, Please specify:

Undecided

Please specify:

We know that it may still be early in the college planning stage and that your plans may change. Please write the names of your top three college choices, in order of preference, at this stage in your planning. If you are undecided please write “Undecided” on the first line and leave the other spaces blank.

1st Top Choice College

2nd Top Choice College

3rd Top Choice College

Describe your career interests. Please use complete sentences

Student Activities

Please list all sports, leadership, college preparation or other extracurricular activities you are involved in at your school or in your community along with the hours per week and leadership positions.

DeleteActivity _ID_
Add your student activity
Extracurricular Activities and Sports (Include Location) Hours per week Leadership Position (s)

Add New activity

Student Attitudes

Please rank the list of reasons provided from 1 to 10 (1=Most Important, 10=Least Important) to best describe why you would choose to participate in the Pathways Program.

Delete_ID_
To develop and improve my study skills, i.e., exam techniques. 1 2 3 4 5 6 7 8 9 10 To develop and improve my study skills, i.e., exam techniques. To study in a college environment. 1 2 3 4 5 6 7 8 9 10 To study in a college environment. To improve my test scores. 1 2 3 4 5 6 7 8 9 10 To improve my test scores. To receive advice about applying to college. 1 2 3 4 5 6 7 8 9 10 To receive advice about applying to college. To receive advice covering how to pay for college. 1 2 3 4 5 6 7 8 9 10 To receive advice covering how to pay for college. To meet and study with new people. 1 2 3 4 5 6 7 8 9 10 To meet and study with new people. To take advantage of the program resources, i.e., library, computers. 1 2 3 4 5 6 7 8 9 10 To take advantage of the program resources, i.e., library, computers. To receive conditional admissions to Salve for attending. 1 2 3 4 5 6 7 8 9 10 To receive conditional admissions to Salve for attending. To have the opportunity to attend academic lectures. 1 2 3 4 5 6 7 8 9 10 To have the opportunity to attend academic lectures. To improve my chances of attending college. 1 2 3 4 5 6 7 8 9 10 To improve my chances of attending college.

Please rank reasons

What other reasons do you have for applying to become a Pathways Scholar?

Please indicate your level of agreement or disagreement with each of these statements.
Please check one answer for each statement

Delete_ID_
I do more than what is expected of me. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I do more than what is expected of me. In dealing with difficult problems, it is very important to evaluate as many pieces of information as possible. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all In dealing with difficult problems, it is very important to evaluate as many pieces of information as possible. I leave tasks until the last minute Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I leave tasks until the last minute I do not like when people challenge my opinions. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I do not like when people challenge my opinions. I like to know the news of the world. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I like to know the news of the world. I'm inclined to forgive others. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I'm inclined to forgive others. I joke around a lot. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I joke around a lot. I say what I think. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I say what I think. I make friends easily. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I make friends easily. I work hard to complete assignments. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I work hard to complete assignments. I respect others. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I respect others. I am a very organized person. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I am a very organized person. I take responsibility for what happens. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I take responsibility for what happens. I am interested in learning about different cultures. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I am interested in learning about different cultures. I check over my work. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all I check over my work.

Please check one answer for each statement

Section 2

Short Answer

Please respond to each prompt using three to five complete sentences.

Describe your strengths, both academic and personal.

Describe the areas, both academic and personal, in which you believe you need the greatest amount of improvement.

Please provide your personal definition of leadership, using examples.

What or whom inspires you to be successful?

Section 3

Family Information

Do you qualify for free or reduced-price lunch at your school?

Yes

No

I don't know

Who is your primary caregiver? Please select only one choice.

Please describe

PROVIDE as much information as possible, regardless of marital status or current living situation

*DO NOT LEAVE ANY SECTION BLANK*

Guardian 1:

DeleteParent _ID_
Parent Information - Click Link Below
Name: Relationship Relationship Mother Father Step-Mother Step-Father Legal Guardian Other Please describe: Occupation and Job title of Parent 1 Employer - Company Name Work Address, City, State, Zip Cell Phone Work Phone Email Adddress Country of Birth Highest Level of Education (select 1): Highest Level of Education (select 1): Did Not Compete High School High School Graduate/GED Some College/University 4-Year College Degree Advanced Degree (Master's, Ph.D.) Other In what country was the highest level of educated completed? Guardian 2

Enter Parent information

Household Information

What is the primary language spoken at home?

If there are any other languages spoken at home, please list them:

Number of family members residing in household

Rentor Own home

Please list siblings (include ages, current level of education, name of current school, degrees earned, and colleges attended [if applicable])

Student Contract

In order to participate in the Pathways Program, I agree to the following statements (Please check all points):

I understand that Pathways is a college preparatory program and that by participating, I am agreeing to apply for, attend and graduate from college (2 or 4 year), or other post-secondary education.

I understand that Pathway is an academic program that assists me in my academic pursuits while in high school and will track my success during my college career.

I understand I am required to maintain a 2.7 quarter GPA and cumulative weighted GPA of 2.7 or higher or I will be placed on Performance Alert with the Pathways Program.

I understand that I am to participate in scheduled workshops, field trips and cultural activities as advised.**(Prior approval of absence from any activity must be granted by the Pathways staff in order to make up activities)**

I agree to keep the Pathways staff informed of any extra-curricular activities that I am involved in and will work with the Pathways staff to ensure that I remain in good academic standing and maintain all requirements of the program.

I understand that I am required to attend the Pathways Summer Component.

I agree to behave in a mature and responsible manner with my parents, teachers, tutors, administrators, Pathways staff and my peers by following all community, school and Pathways rules, as well as show respect for myself.

Parent/Guardian Questionnaire and Release form

Your Parent/Guardian needs to complete a release form so we can access your record AND must complete the "Parent Questionnaire" before your application is considered complete. Please enter the first name, last name and valid email address for a parent guardian. Indicate what the language spoken by your parent/guardian.

Parent/Guardian First Name

Parent/Guardian Email

Language spoke at home by Parent/Guardian

Other Language

Signature

Please check the following two statement and print your name below.

I understand that I am agreeing to participate fully in all academic and social components of the Salve Regina Pathways Program.

I further agree to comply with all rules and regulations established by the Director and staff of the Pathways Program.

Signature

Click to Sign...