College Connection Camp Application

Educational Experience:

Secondary School/High School you now attend/ graduated from:*

Entry Date*

(Expected) Graduation Date*

Type of School*

School Address*

City State / Province / Region ZIP / Postal Code Country

Phone Number*

If you received a GED, list date

What challenges (if any) do you have in the classroom? Please select all that apply*

Not enough time
Difficulty writing
Difficulty paying attention
Blurting out answers
Sequencing/Prioritizing
Difficulty with written material
Difficulty with group instruction
Difficulty getting organized
Other

If other, please specify:

What previous accommodations have you had in the classroom? Please select all that apply.*

Additional time
Calculator
Assisted technology
Assistance with note taking/supplemental notes
Computer
Preferred seating
Other

If other, please specify:

List any other secondary schools, including summer schools, you have attended, beginning with 9th grade.

School 1

Name of School:

Location

City State / Province / Region ZIP / Postal Code Country

Dates attended:

Reason for attendance:

School 2

Name of School:

Location

City State / Province / Region ZIP / Postal Code Country

Dates attended:

Reason for attendance:

School 3

Name of School:

Location

City State / Province / Region ZIP / Postal Code Country

Dates attended:

Reason for attendance:

List all colleges/universities at which you have taken courses for credit (if any).

College/university/technical school 1

Name of College/University/Technical School:

Location

City State / Province / Region ZIP / Postal Code Country

Dates attended:

Class(es) taken:

College/university/technical school 2

Name of College/University/Technical School:

Location

City State / Province / Region ZIP / Postal Code Country

Dates attended:

Class(es) taken:

College/university/technical school 3

Name of College/University/Technical School:

Location

City State / Province / Region ZIP / Postal Code Country

Dates attended:

Class(es) taken:

kquarterman@seguecenter.org

(214)561-7668

College Connection Camp Application

Step 1 of 4

Family Information:

Diagnosed Learning Difference or Social Challenge (please select if applicable):

Educational Experience:

List any other secondary schools, including summer schools, you have attended, beginning with 9th grade.

School 1

School 2

School 3

List all colleges/universities at which you have taken courses for credit (if any).

College/university/technical school 1

College/university/technical school 2

College/university/technical school 3

Briefly describe any scholastic distinctions or honors you have won since the 9th grade (e.g., National Merit, Cum Laude Society)

Getting to Know You

How did you hear about College Connection Camp?

Work Experience during past 3 years (Paid or Volunteer):

Extracurricular Activities during past 3 years:

Sports/Hobbies/Activities you Enjoy:

Person(s) legally responsible for registration decisions:

Person(s) responsible for financial requirements:

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