General InformatIon

Name: ______________________ Relationship to Student: __________________Phone: _________________Street Address: ______________________________ City: __________________ State: ____ Zip: __________

Semester: Fall 20____ Spring 20____ Summer 20____

Associate of Arts Degree Candidate Early Childhood Education Human Services Administration General Studies

Certificate Candidate Early Childhood Education Human Services Administration General Studies Infant/Toddler ECE Health, Nutrition and Food Safety Elder Care Case Management Management Direct Service Worker OST ECE Administration & Leadership Youth Program Administration OST

Child Health Care, Safety and Nutrition Professional Studies (Does not qualify for Financial Aid) Subject: __________________________

FOR OFFICE USE ONLY DATE RECEIVED: ________ GED HS DIP

HiSet OTHER FEE PD DATE: _______ WAIVED

ADVISOR: __________________________

First Name: ___________________________ MI: ____ Last Name: _______________________ SUF: ________

Street:___________________________________________ City:____________ State:______ Zip Code:_______

Male ____ Female ____ Date of Birth: ____________ Alien Reg. #_______________Soc. Sec. # ______________

Phone: (personal)__________________(work)__________________Email: ______________________________

emerGency contact

ProGram of Study

How did you hear about Urban College? ( Check all that apply) Friend/Family Radio MBTA UCB Mailing Television UCB Student Work UCB Website Newspaper UCB Staff

Other: ____________________

Admission ApplicationUrban College of Boston

2 Boylston Street, 2nd Floor, Boston, MA 02116 Tel: 617.449.7039 Email: contact@urbancollege.edu

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Do you have a disability? YES NO If yes, please explain: _________________________Please list your country of citizenship:______________________________________________________What is your native language? ___________________________________________________________Are you a United States Veteran? YES NO Why are you attending college at this time? (Please check all that apply.) To start a new career To improve self To explore options Need specific course/s for job Other: ____________________________________________

What are your long-term educational goals? College Courses Certificate Associate’s Degree Bachelor’s Degree Master’s Degree Doctorate Other: _______________________________________

What is the highest level of education you received prior to attending Urban College? 0-8 grade 9-12 (non-graduate) Attended college, did not graduate Associate’s degree Bachelor’s degree Master’s degree Doctorate degree Some graduate courses Some post-graduate courses Are you the first person in your family to go to college? YES NO

High School School Name: ________________________________________ Date of Graduation: ___/___/____Address: ____________________ City: ________________ State: _____ Country:________Zip: __________

GED/HiSet State In Which Received: ___________________________________ Date Granted: ___/___/____

College or UniversityUniversity Name: _________________________Date of Graduation: ____/____/____ Country: ________________________________Address: ________________________________City: _______________ State: _____ Zip: ______

other InformatIon

Why did you choose to apply to Urban College rather than another college or university? Cost & Location Specific courses Convenient hours Courses in my language Reputation of the school Quality of faculty Other: _________________________________

educatIon hIStory

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Urban College is home to one of the most diverse student bodies in New England. By providing the following information, you are assisting UCB in obtaining much needed grants and other forms of funding. This information is completely confidential and will not affect admissions decisions. Thank you so much for your cooperation.

Race/Ethnicity: (Please check one.) Asian/Pacific Islander Black Hispanic Native American White Other: _______________

Family Status: (Check all that apply.) Single male parent/guardian Single female parent/guardian Two parent household Single person (no children) Two-person household (no children) Single parent living with relatives Single person living with relatives Household Size: Number of persons in household (including you) : ____How many persons in your household are over age 18? __________________How many persons in your household are under age 18? _________________What are their respective ages? _____________________________________ Where do your children attend school? _____________________________________________________________________________________________Is there a dependent elder in your household? YES NO

Students planning to enroll in more than two classes at UCB will be required to have health insurance. This is a legal requirement of the Commonwealth of Massachusetts that applies to UCB. Students should be prepared to sign a waiver and provide proof of insurance coverage. Students taking four courses must provide immunization records. Do you receive private health insurance? YES NO If yes, is your entire family covered? YES NO Type of Health Insurance? Medicare Masshealth Medicaid Other: ________________________ What is your current household income? Under $11,490 $11,491-$15,510 $15,511-$19,530 $19,531-$23,550 $23,551-$27,570 $27,571-$31,590 $31,591-35,610 $35,611-$39,630 $39,631 +

What are your sources of income? (Please circle the primary source, and check all that apply.) Full-Time Employment Part-Time Employment Social Security SSI/SSDI Alimony TANF Unemployment Pension EAEDC No Income Child Support Food Stamps/SNAP Other: ________________________

If you are employed, please list the name of your employer/s: ________________________________________

What is your housing status? Rent, No subsidy Rent, Section 8 Rent, Public Housing Homeless, In Shelter Homeless, with friends or family Home owner Other: _________________________

demoGraPhIc ProfIle

houSehold Income

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Please read the following commitment information for Urban College of Boston students.

Urban College of Boston will assess your writing skill level so you can be placed in courses appropriate to your skill level. Attendance is required for classes. Approximately 3-6 hours of homework is assigned weekly for each 3-hour class. As an Urban College student, you will be required to make a number of financial investments in your education (tuition and fees, books, etc.) New students are required to attend an orientation session, and all students must meet with an advisor at least once each semester. We encourage students to apply for financial aid by completeing a FAFSA application each year.

I hereby certify that the above and enclosed information is true and complete to the best of my knowledge. I also understand that as a candidate for an Associate of Arts degree or a Certificate of Achievement, I must submit a copy of my High School or GED Diploma to the Urban College of Boston before my application can be considered complete, and that willful actions that constitute inappropriate conduct on my part may result in rejection of my application or my withdrawal from college.

Signature: _________________________________________ Date: ______________________________

$10 non-refundable application fee (cash, check, money order, debit/credit). For Degree and Certificate Candidates only.

Urban College of Boston is an affirmative action/equal opportunity institution and does not discriminate on the basis of gender, age, religion, race, color, disability, sexual orientation, or national and ethnic origin in the administration of its educational policies, employment policies, and other programs and activities.

Urban College of Boston is accredited by the New England Association of Schools and Colleges, Inc. through its Commission of institutions of Higher Education. Inquiries regarding the accreditation status by the New England Association should be directed to the administrative staff of the institution. Individuals may also contact: Commission on Institutions of Higher Education, New England Association of Schools and Colleges, 3 Burlington Woods Drive, Suite 100, Burlington, MA 01803. Phone: (781) 425-7700. E-mail: cihe@neasc.org.

Urban College of Boston is a 501© 3 non-profit organization.

Welcome!¡Bienvenidos!欢迎光临!

urban colleGe of boSton commItment

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