The Providence on Southmore

First Name*

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Last Name*

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Phone Number*

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Email*

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Street Address*

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City*

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State*

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Zip Code*

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Date of Birth

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MM/DD/YYYY

Gender

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Ethnic Background

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Parent Guardian Contact

Mother's Name

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Telephone Number

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Email Address

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Father's Name

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Telephone Number

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Email Address

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Who lives in your household? What relationship do you have to the person?

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Major

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Where will you live during school months (Address)?

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City

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State

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Zip Code

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Will you be the first in your family to go to college?*

YesNoInvalid Input

Your High School*

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Your Graduation Rank*

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Your GPA at Graduation*

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Graduation Date

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MM/DD/YYYY

Can you commit to participating in life coaching? (3)*

YesNoInvalid Input

Can you commit to participating in a mentoring relationship? (4)*

YesNoInvalid Input

Can you commit to participating in academic support if needed? (5)*

YesNoInvalid Input

Can you commit to participating in volunteer opportunities? (6)*

YesNoInvalid Input

Electronic Signature*

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Date*

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MM/DD/YYYY

1. Graduation rates are measured in 6 year periods. Participants must commit to college completion within 5 years and remain on track to be supported by the program.

2. Participants that receive support must commit to being full-time students and cannot work more than 20 hours per week to maintain their active status with the program.

3. Participants will be required to meet with a life coach as needed)per agreed upon schedule to address concerns with personal and academic decisions.

4. Participants will be required to meet with a professional mentor as scheduled.

5. Participants will be required to receive academic support (as needed) to ensure scheduled graduation date is realized.

6. Participants will be required to participate in volunteerships to support community efforts as per agreed upon schedule.

Participation Support Application

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