Puente Project Application and Commitment Form Austin Community College Answering these questions is voluntary. The information will remain confidential and will be used to assist you in developing an educational plan to meet your academic goals.

Student’s information First Name___________________________ Last Name ________________________________ ACC Identification Number_______________________________________________________ Address ______________________________________________________________________ City_______________________ State_____________________________ Zip Code _________ Preferred Phone Number 1_______________________ Preferred Phone Number 2_______________________ Personal E-mail ________________________________________________________________ ACC E-mail __________________________________________________________________ High School Graduate?

Yes________

No _________

Name of High School_____________________________________ Year Graduated_________ Referred by (name of Counselor, Administrator, Teacher)_______________________________ College Units Completed_________ Other Colleges Attended____________________________ Major________________________________ Career Goal_____________________________ Ethnicity____________________________ Birth Date_____________ Gender_____________ Assessment Scores: Reading________

Writing________

Essay_________

Do you plan to transfer to a four-year institution? Are you eligible for financial aid?

Yes_____ No _____ Don’t Know______

Yes_____ No _____ Don’t Know______

Are you planning to work while attending ACC?

Yes_____ No _____ Hours/week______

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Information of a parent, a family member or someone close who will know how to contact you, and who can also be reached in case of an emergency: Last name___________________________ First Name ________________________________ Relationship ___________________________Phone __________________________________ Address_______________________________________________________________________ City_______________________ State_____________________________ Zip Code _________

Student’s Family Doctor Name ________________________Phone_______________________ Name any special medical conditions/allergies________________________________________

IMPORTANT, THIS APPLICATION, COMMITMENT AND CONSENT FORMS MUST BE RETURNED BY AUG-19-2015

Return to: Olga Eckert, Puente Advisor ACC Riverside Campus 1020 Grove Boulevard, Room 8121 Austin, TX. 78741 Ph: 512.223.6319 [email protected]

Rosa Rodriguez-Alvarez, Puente Counselor ACC Riverside Campus 1020 Grove Boulevard, Room G8114 Austin, TX. 78741 Ph: 512.223.6017 [email protected]

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Puente Student Commitment Agreement, Fall 2015 I agree to make full commitment to the Puente Program. This commitment includes the following:

 Fall 2015, enroll in English 4.0 paired with DEVW 0130 and EDUC 1300.  Spring 2016, enroll in English 1302 and Mexican History.  Receive an electronic device (Ipad), at the beginning of the program, and use it in a responsible

   

way. Turn in the device to the Puente coordinator during the Winter Break, and get it back at the beginning of the Spring semester. (Upon successful completion of the program, and to the Puente coordinator discretion’s, I may be eligible to own the device at the end of the Spring semester). I will attend all class sessions regularly and inform the Puente instructor in the event of an absence, via Email notice. Attend and participate in all Puente Meetings. Actively engage with the Puente familia. Agree to the mentor-mentee partnership. In the event that I no longer wish to participate in the program, I will notify the Puente coordinator as soon as possible.

Student’s Name (Please Print):____________________________________ Student’s Signature: ____________________________________ Date: __________________ If the person signing is less than 18 years of age, the parent or guardian should also give consent, as follows: I hereby certify that I am the parent or guardian of ________________________, the participant named above, and I do give my consent without reservations to the foregoing on behalf of him or her or them. Signature of Parent or Guardian: ______________________________ Date: _____________________ Counselor’s /Recruiter’s Signature: _______________________

Date: __________________

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Consent to Use my Picture, Name and Written/Oral Statements I understand that Austin Community College District (ACC District) is undertaking initiatives to promote the College and its programs. I wish to assist in these efforts and hereby grant ACC District permission as follows: 1.

I permit ACC District and its authorized agents to use, re-use, publish, and re-publish, in any medium, in whole or in part, without restrictions as to changes or alterations, photographs of me individually or group photographs in which I am included.

2.

I permit ACC District and its authorized agents to use my name and/or major if ACC District so chooses.

3.

I permit ACC District to use written statements or quotes by me that I may provide to them about ACC District and my experiences there.

In signing the Consent I understand and acknowledge that: • My photograph, name, or statement may be used for ACC District purposes in slide/tape presentations, film, videotape, or electronic communication productions for instructional, informational, promotional, or other purposes. • I will not receive any remuneration for the use of my name, photograph, or quote. • I release ACC District’s trustees, president, appropriate vice presidents and other administrators, faculty members, and staff from liability for any claim or course of action resulting from or in any way related to the use or publication of such photographs or statements. • Said material is the sole property of Austin Community College District or its assignees. • I am over 18 years of age and otherwise legally competent to sign this Consent. • I have read this Consent in its entirety and understood it prior to executing it.

 Yes, I give permission  No, I do not give permission Name (Please Print): ________________________ Signature: ____________________ Date: ________________________ If the person signing is less than 18 years of age, the parent or guardian should also give consent, as follows: I hereby certify that I am the parent or guardian of ________________________, the participant named above, and I do give my consent without reservations to the foregoing on behalf of him or her or them. Signature of Parent or Guardian: ______________________________ Date: _____________________

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