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ASMA

Program Overview

Cultural Framework

Student Application

Student Data Form

Student Checklist

Student Contract Agreement

Student Application

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Mt. Sac Application

Stakeholders

SCHOLAR APPLICATION

Scholar Information

First Name:

Middle Initial:

Last Name:

Today's Date:

Birth Date:

Home Address:

City:

State:

Zip Code:

Home Phone:

E-mail:

Ethnicity:

Grade Level:

Expected Year of High School Graduation:

School Name:

City:

Are you eligible for free or reduced lunch
Yes
No

Are you a:
U.S. Citizen
Permanent Resident

Parent/Guardian Information

Student currently lives with:
Mother
Stepmother
Father
Stepfather

Other (specify):

Mother/Stepmother/GuardianName:

E-mail Address:

Mobile Number:

Emergency Phone Number:

Father/Stepfather/Guardian Name:

E-mail Address:

Mobile Number:

Emergency Phone Number:

Education Level
(Check one for each parent: M = Mother/Stepmother, F=Father/Stepfather)

Never Attended
M F

GED
M F

Six years or less
M F

High School Graduate
M F

Junior High
M F

Some College/University
M F

Finished Junior High
M F

Two-year college grad
M F

No high school
M F

Four-year college/Univ. grad
M F

Some High School
M F

Postgraduate study
M F

If attended College/University, indicate here

Mother:

Father:

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