Learn how to get along better with my brothers, sisters, or parents Learn how to dress more attractively ____ Learn how to make friends …
Date Received ___________
KANSAS STATE UNIVERSITY
GEAR UP I APPLICATION
201 Holton Hall
Manhattan, KS 66506
785-532-5380
Funded by the United States Department of Education
STUDENT INFORMATION
Please read the following statement and answer all questions carefully
ALL information requested must be provided
Name ____________________________ SSN _____-___-____ Date of Birth
____/____/____
Last First Middle Initial
Month/Day/Year
Address _______________________________ Home Phone __________________ Age
_____
Number and Street Name or Route
______________________________________ School __________________ Grade
________
City State Zip
Ethnic/Racial Background:
|____ African-American |____ Native American |____ Asian American |
| | | |
|____ Puerto Rican |____ Mexican American |____Cuban American |
| | |
|
|____ White |____ Other please |__________________ |
| |specify: | |
US Citizen: ____ Yes ____ No Sex: ____Female
____Male
Permanent Resident: ____ Yes ____ No
If not a US citizen
Family Description: List the names of all the people who live in your
house, including yourself, from the oldest to the youngest, and how they
are related to you
Name: ___________________________ Relation: ______________________ Age:
________
Name: ___________________________ Relation: ______________________ Age:
________
Name: ___________________________ Relation: ______________________ Age:
________
Name: ___________________________ Relation: ______________________ Age:
________
Name: ___________________________ Relation: ______________________ Age:
________
STUDENTS GOALS
Do you want to be in GEAR UP I? ____ Yes ____ No
Why or Why Not?
______________________________________________________________
What kind of education do you want to get after high school your
educational
goal?
____________________________________________________________________________
_
What kind of job do you want to get after you complete high school your
career goal?
____________________________________________________________________________
_
What four things do you want to accomplish this year your personal goals?
1 ______________________________ 3 _______________________________
2 ______________________________ 4 _______________________________
ACADEMIC
The staff will assist you in developing good study skills and habits during
the academic year and summer programs You will also receive tutoring in
your school courses Please list below those courses in which you may want
tutoring
1 ______________________________ 3 _______________________________
2 ______________________________ 4 _______________________________
What is your current grade point average GPA? _______________
Are there any special academic needs? If so, please specify:
____________________________________________________________________________
_
List your extra-curricular activities in the school and the community
1 ______________________________ 3
_______________________________
2 ______________________________ 4 _______________________________
PERSONAL AND CAREER COUNSELING
The staff will assist you with issues important to you and your future
They will also be available to counsel you with personal concerns whenever
needed Check below as many of the following areas in which you have an
interest
I would like to:
____ Learn how to get along better with my brothers, sisters, or parents
____ Learn how to control my temper
____ Learn how to stop fighting when I am angry
____ Learn how to be less shy
____ Learn how to be more comfortable on dates
____ Learn how to dress more attractively
____ Learn how to make friends
____ Learn how to make good decisions
____ Learn how to set and accomplish goals
____ Learn how to be a group leader
____ Learn how to solve problems and conflicts with teachers
____ Learn how to express my feelings
____ Learn how to evaluate my strengths and weaknesses
____ Learn how to trust others
____ Learn how to handle stress
____ Learn how to make career decisions
____ Learn how to speak in front of groups of people
____ Learn how to improve my self-image
____ Learn how to expand my social,
cultural, and recreational options
____ Other please describe:
_____________________________________________________
SOCIAL-CULTURAL-RECREATIONAL
GEAR UP I will sponsor activities for all students to attend Activities
include: social parties, movies, games at K-State, cultural going to
plays, ballets, museums, etc, and recreational bowling or skating
events
I would like to:
____ go to more cultural events than I do now
____ attend more social events than I do now
____ participate in more recreational activities than I do now
I understand the goals, structure, and requirements of GEAR UP I, and I
agree to assume the responsibility for participating in both the school
year and summer components
_________________________________________
_______________________
Students Signature
Date
