Catalyze Student Recruitment - Formstack

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Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Thank you for applying to have a College Possible success coach work one-to-one with you at your institution! If you have any questions, please reach out to catalyze@collegepossible.org.

First Name*

Middle Name

Last Name*

Nickname (optional)

Gender*

Agender Bigender Female Genderqueer/Non-conforming Male Not Listed Trans Female Trans Male

High School Name*

High School Graduation Year*

College Name*

Austin Peay State University California State University, Stanislaus California State University, San Bernardino-Palm Desert Campus Luther College Metropolitan State University Saint Cloud State University University of California, Santa Cruz University of Cincinnati-Main Campus Vaughn College

College Student ID Number*

College Graduation Year*

Anticipated College Graduation Year (ex. 2016)

Intended Area of Study/Declared Major*

GPA

Current cumulative college GPA

Mobile Phone Number*

Email*

Street Address*

City*

State*

Zip Code*

Are you currently receiving a Pell grant?*

Yes No Unsure

Are you DACA or Dream Act eligible?*

Yes No Unsure

Are you a first-generation college student?*

Yes No Unsure

Have you applied to, or are you already a member of, a TRiO or opportunity program on your campus?

Yes No Unsure

Are you currently receiving individualized support as a part of another college success program on campus?*

Yes No

If yes, please list below:*

How did you hear about the College Possible program on your campus?*

Why are you interested in working directly with a College Possible Success Coach who will help you navigate through school this year?*

I am most easily accessed by:*

Cell Phone Text Message Email

Your answer will indicate to your coach how they should anticipate communicating with you.

Which is the best time to reach you:*

Morning (8am - Noon) Afternoon (Noon - 5pm) Evening (5pm - 8pm) Other

If Other, please indicate your preferred time:*

Academic Release Form

I request that my post-secondary institution release all academic and financial information to a College Possible representative.This information may include academic charges/credits/payments, grades, registration, academic progress, enrollment, financial aid application and awards, and demographic information. In addition, I request that College Possible have access to view my academic record through college graduation. This information will be used by College Possible staff to verify student information and provide programmatic support. (Check one box below. Your selection can be changed at any time by contacting College Possible.)*

I give College Possible permission to share my name, demographic and contact information with my high school, partner colleges or other organizations. This information will only be shared for the purpose of connecting College Possible students with additional resources. I do not give College Possible permission to release my name, demographic and contact information to colleges or other organizations.

Date of Birth*

Signature

Use your mouse or finger to draw your signature above

Date*

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