High School Program Application

Student's Name*

First Last

Gender*

Date of Birth*

Ethnic Background*

Select one.

Please select the area or region that best describes the area you live in.*

Northern California
Inland Empire
Central Valley
Southern California
Coachella Valley
San Diego

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell or Other Phone*

Email*

Enter Email Confirm Email

Email is the primary form of contact for Experience Berkeley. Please ensure you provide us with an email you check consistently and that you have no mistakes when you enter it. (No school emails please.)

Parent / Guardian's Name*

First Last

Parent / Guardian's Phone (if different)

Academic Information

High School Name*

High School City*

City

GPA (Unweighted)*

Please enter a value between 0.00 and 4.00.

GPA (Weighted)*

Please enter a value between 0.00 and 5.00.

Expected Graduation Date (mm/dd/yyyy)*

About You

How did you hear about the Experience Berkeley Program?*

(ex: Facebook, friend, former participant, counselor etc) *If a counselor, please state their name.

What are some honors or awards you have received? Please list those from high school only (MAX 5)*

If you wish, please bring to our attention any special circumstances that might bear on our interpretation of your credentials or for which we may need to make accommodations to facilitate your participation (If none, mark N/A)

Employment History (if applicable)*

Please make sure to include how many hours a week you work

In rank order, what are your top 3 choices for college and WHY (for each school)?*

Unofficial Transcript*

Please make sure it shows a cumulative GPA

Intended College Major*

WIll you be involved in any additional summer programs, internships, etc ?*

Personal Statements

Directions: Please answer each of the following 4 short essay questions (300 maximum word limit for each essay).

Essay 1*

Think about an academic subject that inspires you. Describe how you have furthered this interest inside and/or outside of the classroom.

Essay 2*

What resources, programs, or educational opportunities have you taken advantage of to prepare for college? How have these opportunities prepared you for college?

Essay 3*

Describe example(s) of any sustained leadership experiences and roles in your home, school, or community. What skills have you developed in these leadership roles?

Essay 4*

Share an example of a hardship or challenge that you have overcome while in high school? What did you learn from this challenge or hardship? (Hardships are economic, environmental, educational, cultural, or health challenges you face in your school or home life).

Background Information

Do you live with*

both parents
a single parent
a relative
Other

Father / Legal Guardian's Highest Level of Education*

What is/was your father's/legal guardian's primary occupation?

Mother / Legal Guardian's Highest Level of Education*

What is/was your mother's/legal guardian's primary occupation?

Number of people in household?*

What was the approximate total income of all the persons living in your parents’ household last year?*

Are you eligible for free/reduced lunch?*

Are you a first generation college student?*

Would you be the first in your family to attend & graduate from a 4-year college in the United States?

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

In consideration of being permitted to participate in any way in the Experience Berkeley program, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Stiles Hall, its officers, employees, and agents from liability from any and all claims including the negligence of Stiles Hall, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in the Experience Berkeley program. By clicking Submit, you agree and digitally sign the application.

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Stiles Hall