Wufoo
Expanded Horizons Program Application 2017-18
Please fill out this application if you are interested in the Expanded Horizons College Success Program
NOTE: A short answer response is required for this application. You will not be able to save the application and return to it later. We suggest you write your short answer response in a word document and then copy and paste in to this application.
Student Demographics and Contact Information
Name
*
First
Last
Permanent Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
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Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau SAR China
Republic of North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Personal Email
*
Cell Phone Number
*
###
-
###
-
####
Parent/Guardian Phone Number
*
###
-
###
-
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Gender
Gender
Male
Female
Other gender identity
Date of Birth
Ethnicity (Check All That Apply)
Black/African American
Asian/Pacific Islander
Latino/a
Native American
White (non-Latino/a)
Other
If you checked other please list here:
Current High School you are attending:
*
In 2017-2018, I will be a:
*
Freshmen
Sophomore
Junior
Senior
OSIS/ID #
*
Name of Guidance/College Counselor
*
What is your current GPA/Academic Average?
Do you currently have an IEP (individualized education program)?
Yes
No
Unsure
Will you be the first in your immediate family to go college?
Immediate family includes just parents and siblings.
Yes
No
Highest level of Education completed by Parent/Legal Guardian
Middle School
High School
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate or Professional Degree ( ex. PHD, Dr., JD)
Gross Household Income (before taxes):
Number of people in household (including you) :
Are you Eligible for Free or Reduced Lunch?
Yes
No
Is your family receiving SNAP or Public Assistance?
Yes
No
Do you have medical insurance ?
Yes
No
Insurance Name/Member #:
Do you have dietary restrictions?
Do you have any allergies?
T-Shirt Size
Parent/Guardian Contact Information
Parent/Guardian 1 Name
*
First
Last
Parent/Guardian 1 Phone Number
###
-
###
-
####
Parent/Guardian 1 Email Address
Parent/Guardian 2 Name
*
First
Last
Parent/Guardian 2 Phone Number
###
-
###
-
####
Parent/Guardian 2 Email Address
Who is your Emergency Contact?
Parent/Guardian 1
Parent Guardian 2
Other
if you selected OTHER, who is your emergency contact? Include Name and Number.
Required Documents
Upload required documents below.
If you are having trouble uploading documents you can also fill out a paper application and bring paper copies of these documents in.
1040 Tax Form or Budget Letter
*
Please Answer the Essay Question below
*We encourage you to write your essays in a word doc and copy and paste it here when you are ready to submit*
Essay Question:
Please explain why you want to be a part of the Henry Street Settlement Expanded Horizons College Success program. Why do you dream of going to college? What or who has most inspired you to think about your future goals?
(250 words or less)
Maximum of
250
words.
Currently Used:
0
words.
As the applicant, I also am willing, able, and eager to participate in the Henry Street Settlement Expanded Horizons College Success Program. If I am selected, I will be an active member of the program, and will respect my peers, counselors, and all staff. I understand that this program is a big commitment, and I am willing to commit to attending the summer bridge program and bi-weekly classes during the academic year.
*
I understand
Attach Most Recent Transcript or Report Card
*
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