Options for College Success Application for Admission

PERSONAL INFORMATION
Name *
Name
Marital Status *
Date *
Date
Birth date
Gender *
Citizenship *
Citizenship
(if applicable)
(if applicable)
Race
Address *
Address
Phone *
Phone
Cell Phone
Cell Phone
FAMILY INFORMATION
Family Information
Please list the adults who have legal rights and responsibilities toward you. If a minor, this is usually one or both biological parents when living. If you wish, you may list on an attached sheet step-parents and/or other adults with whom you reside, or who otherwise help care for you. Parents' Marital Status (relative to each other):
If Divorced, please specify date
If Divorced, please specify date
With whom do you make your permanent home?
PARENT/GUARDIAN 1
Address (if different than yours)
Address (if different than yours)
Home phone
Home phone
Cell phone
Cell phone
PARENT/GUARDIAN 2
Address (if different than yours)
Address (if different than yours)
Home phone
Home phone
Cell phone
Cell phone
Please give the names and ages of your siblings, college (if any), degree(s), dates.
EDUCATIONAL INFORMATION
Date of entry
Date of entry
Date of secondary school graduation
Date of secondary school graduation
Address of school *
Address of school
Phone
Phone
Fax
Fax
Please select any that apply *
If you received a GED, date:
If you received a GED, date:
Official scores must be sent from the testing agency
Please check accommodations you have had in the past
STANDARDIZED TEST INFORMATION
Please include a copy of the most recent Individualized Education Plan, educational and/or neurological testing with this application. This material must be provided for the Student to be considered for admission.
Please note scores in the space.
Please list principal jobs or volunteer opportunities you have help during the past 2 years.
In the classroom *
Please indicate any challenges you have faced in the past
(seizures, head injuries, diabetes, sleep disturbance, allergies, etc.)
Please list any and their purpose.
OTHER INFORMATION
Application fee payment *
A $200 application fee is required.
If there is anything not included on this application that you would like to let us know, please submit directed to info@optionsforcollegesuccess.org
Student Signature *
Student Signature
I certify that all information submitted in the admission process—including the application, any supplements, and any other supporting materialsVis my own work, factually true, and honestly prepared. I understand that I may be subject to a range of possible disciplinary actions, including admission revocation or expulsion, should the information I've certified be false.
Parent Signature *
Parent Signature
I certify that all information submitted in the admission process—including the application, any supplements, and any other supporting materialsVis my own work, factually true, and honestly prepared. I understand that I may be subject to a range of possible disciplinary actions, including admission revocation or expulsion, should the information I've certified be false.
Date *
Date
INFORMATION RELEASE
I am applying to the OPTIONS FOR COLLEGE SUCCESS. I grant my permission for OPTIONS FOR COLLEGE SUCCESS to contact any person, organization, or school (including, without limitation, any healthcare provider or educational provider) listed in this application. I consent to the release of any and all information about me by any person, organization, or school (including, without limitation, any healthcare provider or educational provider) listed in this application. I grant my permission for OPTIONS FOR COLLEGE SUCCESS and any person, organization, or school (including, without limitation, any healthcare provider or educational provider) listed in this application to discuss anything about me. This consent shall continue until withdrawn in writing by me. In addition, I authorize the release of my admission decision to my secondary school and my postsecondary school
Student Signature *
Student Signature
Parent Signature
Parent Signature
Date *
Date

OPTIONS FOR COLLEGE SUCCESS is committed to fulfilling its mission without discrimination on the bases of race, color, national origin, religion, age, sex, gender, sexual orientation or veteran status