SIMON’S ROCK COLLEGE OF BARD

Office of Admission 84 Alford Road Great Barrington, MA 01230

EMERGENCY ADMISSION PROGRAM
Phone: 800-235-7186 Fax: 413-528-7334 admit@simons-rock.edu

Simon’s Rock College of Bard is offering an emergency admission program for eleventh and twelfth grade students affected by Hurricane Katrina. Admitted students will be permitted to enroll on a semester-by-semester basis for the remainder of this academic year. Interested students should submit the emergency application as soon as possible and applications will be reviewed immediately. Financial assistance for tuition, room, board, and transportation costs is available and will be awarded on a case-by-case basis. Students will receive support in adjusting to campus life and in catching up on missed coursework. Simon's Rock College of Bard is the only four-year college of the liberal arts and sciences specifically designed to provide bright, highly motivated students with the opportunity to begin college in a residential environment after the tenth or eleventh grade. Students who successfully complete the requirements receive the Associate of Arts (A.A.) degree after two years of study, and the Bachelor of Arts (B.A.) degree after four.

PERSONAL INFORMATION
Legal Name
Enter name exactly as it appears on birth certificate, passport, or other official documents.

Usually called Current Address

Birth date
Month Number and Street

/
Day

/
Year

Gender
Apt. No. Country Zip or Postal Code

City/Town

State/Province

Phone Cell phone

Fax Email

Citizenship
US citizen Dual US citizen; please specify other country of citizenship US Permanent Resident visa; citizen of Alien Registration Number Other citizenship
Country(ies) Visa type

If you are not a US citizen and live in the US, how long have you been in the country?

The following information is optional:
Please check all that apply:
African American, Black American Indian, Alaska Native (tribal affiliation Islander Asian American (country/ies of family’s origin Asian, including Indian subcontinent (country/ies Hispanic, Latino/a (country/ies enrolled ) ) ) ) Mexican American, Chicano/a Native Hawaiian, Pacific Puerto Rican White, Caucasian Other (specify ))

First language if other than English Place of Birth
City/Town

Language(s) spoken at home
State/Province Country

Social Security Number (if any)

FAMILY INFORMATION
Parent/Guardian 1 Name
Last First Middle

Parent/Guardian 2

Name
Last First Middle

Relationship to you Living? yes no

Gender If no, date deceased

Relationship to you Living? yes no

Gender If no, date deceased

Home address if different from yours

Home address if different from yours

Home phone Cell phone Fax Email Parents’/Guardians’ marital status: married separated

Home phone Cell phone Fax Email divorced never married Both widowed

With whom do you make your permanent home?

Parent/Guardian 1

Parent/Guardian 2

Other relation/friend; please specify: If your parents/guardians do not live at the same address, should college correspondence also be sent to the parent/guardian with whom you do not legally reside? yes no If yes, how should it be addressed?

Siblings
Name Age Indicate current grade or college attended

ACADEMIC INFORMATION
School you attend now (or attended most recently) Current grade
.

Dates attended Secondary school graduation year
Number and Street .

School Address

City/Town

State/Province

Country

Zip or Postal Code

Type of school:

public

private

parochial

home school

Guidance counselor’s name

Please include copies of any available high school grade reports or transcripts. If no reports or transcripts are available, submit a chronological summary of courses taken in high school, noting course titles, levels (AP, IB, honors,), credit value, and grades. Please indicate below the title, level (AP, IB, honors, etc.) and credit value of all courses you are taking in the current school year.
First Semester/Trimester Second Semester/Trimester Third Timester

List all other schools you have attended since the ninth grade beginning with the most recent. Include colleges or universities at which you have taken courses for credit. Attach additional sheets if necessary. Name of school Location Dates attended

Have you been out of school for more than one month (excluding summers and other official school vacations) since the seventh grade? yes no If yes, please explain on a separate piece of paper why and what you did during this time. Have you been suspended, expelled, or required to withdraw from any of the schools you attended? If yes, please explain on a separate piece of paper. yes no

ADDITIONAL INFORMATION Standardized Test Scores
If you have taken the SAT, ACT, PSAT, or PLAN, please indicate below the date on which you took the test and the scores you received.
Test taken Date taken/to be taken Scores (if taken)

Test taken

Date taken/to be taken

Scores (if taken)

Interview
An interview is required as part of the application. Interviews can be conducted by phone. Please indicate your plans below. I have had an interview.
Name of interviewer Date

I will call to schedule an interview. I plan to visit campus and be interviewed at that time.
Please indicate date of campus visit.

Essay
If possible, please submit an essay on one of the following topics or a previous school writing assignment or an essay on a topic of your choice or any other sample of your writing. 1. Describe an idea, learning experience, creative process, literary work, or intellectual exercise you have encountered during you’re the last two years and discuss how it has affected your thinking. 2. Discuss some issue of personal, local, national, or international concern and its importance to you. 3. Indicate a person who has had a significant influence on your, and describe that influence.

Student and Parent/Guardian Signatures
Simon’s Rock is academic community in which students are expected to be active and engaged learners, while demonstrating honesty and integrity, and taking responsibility for their actions. By signing this form, the applicant and parent attest that all information contained in this application is complete, factually accurate, and honestly presented. The applicant agrees to contact the Office of Admission should any information contained herein change once the application is submitted.

Applicant Signature

Date

Parent/Guardian Signature

Date