Workforce Equity Initiative Participant Application

Student Contact Information

Name: * Address: * City: * State: * Zipcode: * Cell Phone: Home Phone: * Work Phone: * E-mail: * Major: *

Student Demographic Information

PSC ID: Birthdate: * Age: *

Gender: *

Male Female

Ethnicity: * Select an option:American Indian/Alaskan NativeBlack/African-AmericanLatino-HispanicWhiteAsianOther If Other:

First Generation Status Information

Does your Mother have a Bachelor's (4-year college) degree?

Yes No

Does your Father have a Bachelor's (4-year college) degree?

Yes No

Which parent did you live with and receive support from until you were 18 years old? (Choose One) Mother OnlyFather OnlyBoth Mother and FatherNeither Parents

Student Dependency Information

Are you married?

Yes No

Do you have children?

Yes No

Have you ever been a ward of the court, in foster care, or an emancipated minor?

Yes No

Serving active duty in the armed forces?

Yes No

Active duty U.S. Veteran released under any condition other than dishonorably?

Yes No

Are you under 18 years old with no parents or guardians?

Yes No

Are you homeless or at risk of becoming homeless?

Yes No

Student Participant Agreement With WEI Student Support Services

Phone number to use: If no cell phone, please check box.

For the ability to participate in the program: *

Yes, I agree to full participation No, I do not agree to full participation

WEI Student Needs Assessment

Date: * Current Status: * Select an option:New StudentReturning StudentTransfer Student Comment: Classification: * Select an option:FreshmanSophomoreESL OnlyESL and CreditOther If other: Credit Hours Completed: GPA: Current Credit Hours:

Have you ever had your ability to read, write or do math assessed before coming to PSC?

Yes No

Result/Outcome:

Have you ever taken assessment tests at PSC?

Yes No

If yes, check all that apply.

DRP Reading Math English Placement Essay NYS CELSA ESL Placement Essay TABE (GED) Other

If Other, explain:

Did you receive a General Equivalency Diploma?

Yes No

Date: Location:

Did you graduate from high school?

Yes No

Date: Location:

Other Post Secondary College:

Yes No

Where: Credit Hours: Area/Major:

Were your transcripts evaluated?

Yes No

Reason for Change:

What are your educational goals? Check all that apply:

Certificate Associate Degree Transfer Bachelors Degree Undecided

Area of Study: Comments: 1. Consistently attend classes and labs? * 2. Take good notes in class? * 3. Have good study habits? * 3a. Spend enough time studying? * 3b. Hours per Week: * 4. Understand almost everything your instructor says? * 5. Understand almost everything I read? * 6. Speak well? * 7. Have a good English vocabulary? * 8. Write well? * 9. Have good math skills? * 10. Use the library to help with your studies? * 11. Ask your instructor for help if you need it? * 12. Ask others for help if you need it? * 13. Use tutoring services when necessary? * 14. Usually get good grades? * 15. Are you having problems in any of your classes? * 16. What would help you get better grades in school? * Comments:

Do you intend to transfer to another college or university? *

Yes No Not Sure

Do you need transfer assistance? *

Yes No Probably in the future

Have you applied to any other colleges? *

Yes No

Colleges applied to: * Comments:

Are there personal issues in your life that may affect your ability to succeed in college? Consider issues related to yourself, family and friends. *

Yes No

Explain:

Are you currently involved in any clubs or organizations? *

Yes No

Which one (s)?

Are you interested in becoming involved in any clubs or organizations at PSC? *

Yes No

Explain:

Is transportation a problem for you? *

Yes No

Explain:

Is childcare a problem for you? *

Yes No

Explain: Do you need assistance in any of these areas? *

Are there any other issues that may make it difficult for you to succeed in college? *

Yes No

Explain: Where and when have you exhibited basic knowledge of computer and internet skills or have shown success in an online course? *

Do you have an internet connection at home or away from campus? *

Yes No

Do you own and have regular access to a computer? *

Yes No

Do you have access to or have you begun using your PSC e-mail, username and password? *

Yes No

Where have you demonstrated strength in your reading and writing skills? * How have you proven yourself to be a self-motivated and independent learner? * Briefly explain your understanding of the importance of time management and the time commitment in an on campus environment. * How will you show your ability to manage your time and commitment for independent on and off campus study? *

Are you employed? *

Yes No

Hours per week: Comments:

Would you be interested in finding a different job? *

Yes No

Type of Work?

Do you need financial aid? *

Yes No

Comments:

Have you ever applied for Financial Aid? *

Yes No

If FAFSA, semester last applied: If PSC Scholarship, semester last applied: Other:

Are you receiving financial aid now? *

Yes No

Types: (Check all that apply)

Pell Student Loan STS and Other Grants Scholarships Other

If other, explain: Would you like to comment on any special circumstances affecting your financial situation? Do you have a disability that you want us to know about? *

If so, have you contacted the ADA Coordinator?

Yes No

Have you supplied documentation to the ADA Coordinator?

Yes No

Would you like us to send you more information on disability services? *

Yes No

Comments:

Student Verification

Student Signature *