MESA Community College Program Application

Personal Information

* Campus/Student ID:

* First Name:

Middle (or initial):

* Last Name:

* Birthdate:

(xx/xx/xxxx)

* Gender:

Male
Female

Contact Information

* Address:

* City:

* State:

* Zip Code:

* Email:

Confirm email:

(Must conform to email format)

* Home Phone:

(xxx-xxx-xxxx)

* Cell Phone:

(xxx-xxx-xxxx)

Ethnic Background

* Ethnicity

Other:

American Indian/Alaskan Native tribal affiliation

* Is a language other than English spoken regularly in your home?

Yes No
If yes, specify

Residential Status

* Citizenship or Visa Status (Check one)

U.S. Citizen
Permanent Resident
F1 VISA
Resident Alien
AB 540/DACA

Academic Information

* When did you first enroll at this college:

Year

Current College Counselor:

* Total number of college units completed:

0-29 30-60 60+

* Do you have a Bachelor's degree?:

Yes No

Current College Cumulative GPA:

* Declared Major:

Other:

* What was your first college math class?

Other:

Intended Transfer College(s) – in order of preference:

1.
2.
3.

Prospective date of transfer:

Semester: Year :

Previous school(s) attended:

* High School:

Date:

College:

Date:

College:

Date:

Obstacles that may interfere with your education (check all that apply):

Financial need
Employment issues
Family obligations
Knowledge of educational system
Exceptional needs (specify below)
Other (specify below)

Exceptional Needs:

Other Obstacles:

* Are you employed?

Yes No
If yes, how many hours per week?

* Are you a veteran

Yes No

Parents/Guardian

* Highest level of education achieved by each of your parents/guardians:

Father:
Other:
Mother:
Other:

* Type of work your parents or guardian have done over the past years or prior to retiring:

Father:
Other:

Mother:
Other:

STUDENT CONTRACT

If you are determined eligible for MESA, you are agreeing to follow the student contract below.
Please read the contract through, in order to fully understand what will be expected of you as an active MESA student.

As a MESA student, I agree to the following:

I must follow the MESA Educational Plan as developed with the MESA Counselor to make progress towards my educational goal.

I must enroll in and seek to complete a minimum of 12 units per semester. Any dropping classes must be approved by the MESA Counselor or MESA Director.
I must make satisfactory progress each semester by completing coursework with a minimum 2.50 GPA and maintaining a cumulative GPA of 2.50 or above. Failure to meet these standards may result in the need to develop a personalized contract between counselor and student and possible dismissal
I must meet with MESA staff a minimum of three (3) times per semester. The three times must at least include an Educational Plan with a MESA Counselor and two MESA Workshops/Events or related professional growth activity.
I must participate in activities assigned by the MESA Program (such as tutoring, counseling, classes, workshops, personal statements, resumes, admissions applications, study groups, AEW's, etc.)
I must submit a copy of my resume/bio and personal statement to MESA staff.
I must respond in a timely manner to all mailed notices, e-mail communications, and/or calls made to me by the MESA Program staff.
I must notify the MESA Program staff of any changes in my class schedule, academic major, address, student ID #, phone number, or personal status.
I understand that if accepted into the MESA Program it will be provisional until I complete a MESA Orientation and my MESA Educational Plan.
In order to receive a book/calculator loan for the semester, I understand that I must have an Educational Plan on file and attend at least two MESA Workshops/Events or related professional growth activities the previous semester. If I fail to return a book or calculator loaned to me, a hold will be placed on my student record.
I must apply for the Board of Governors Grant (BOGG), FAFSA, or Dream Act CalGrant form each year that I am a MESA student.
I give my permission for MESA to give my name, phone number, and address to college and employer representatives, and to use my photograph in MESA and college promotional materials.

By applying to the MESA Community College Program, I understand that I give my permission for MESA to obtain information about my performance from colleges and testing agencies, financial aid and other offices to determine eligibility for the MESA program. I may be asked to provide additional information for eligibility determination.

* I certify that I have provided true and correct information.

Today's Date:

Rancho Santiago Community College District values the safety of our community members. The College provides an Annual Safety and Security Report published electronically at http://www.rsccd.edu/Departments/Security-and-Public-Safety/Documents/RSCCD-Safety-Annual-Report-2015.pdf. The report contains several important safety, security, and sexual assault response policies among others; advice on safety topics; campus crime statistics; drug and alcohol resources; and other important safety information. If you would like a paper copy, requests may be made to the Chief, District Safety and Security at 2323 N Broadway, Santa Ana, CA 92706.