Double Discovery Center Application


STUDENT ADMISSION APPLICATION I am interested in the following program: Talent Search Upward Bound (New applicants to the Upward Bound Program must be in the 9th or 10th grade.)
Student's Name: ________________________________________________________________ Address: ______________________________________________________ Apt. #: __________ City: ______________________________ State: _______ Zip Code: __ __ __ __ __ - __ __ __ __ Home Telephone Number: (______)____________________ Gender: Female Male Date of Birth: ______/______/______ Social Security Number: ___________________________ MonthDayYear Email: _________________________________________ Citizenship Status: U .S. Citizen Permanent Resident Other: ____________________ Ethnicity: Asian Black Latino White Other: _________________ Current Grade: 6 7 8 9 10 11 12 Not in school, but I last completed the _______ grade. If applying during the summer: I will be in the _______ grade in September. School Name: ________________________ School Borough: ______________ Current Educational Enrollment: Middle School High School GED Program Other: ____________________ Name of your current Grade Advisor: ____________________________________________ What are your career goals? _______________________________________________________ For Official Use Only - Do Not Mark FG LI Missing: Report Card Incomplete Doc TS UB EII _________
PARENT 1 Check One: Mother Father Legal Guardian Other___________________ Does the applicant reside with you? Yes No Are you a DDC graduate? Yes No Name: ________________________________________________________________________ Address: _______________________________________________________________________ Daytime Telephone: _______________________ Evening Telephone: ________________________ Occupation: _______________________________ Email: _________________________________ Citizenship Status: American Citizen Permanent Resident Other______________ Education Completed: Less than HS Some HS HS Diploma/GED Some College B.A. Degree M.A. or higher PARENT 2 Check One: Mother Father Legal Guardian Other___________________ Does the applicant reside with you? Yes No Are you a DDC graduate? Yes No Name: ________________________________________________________________________ Address: _______________________________________________________________________ Daytime Telephone: _______________________ Evening Telephone: ________________________ Occupation: _______________________________ Email: _________________________________ Citizenship Status: American Citizen Permanent Resident Other______________ Education Completed: Less than HS Some HS HS Diploma/GED Some College B.A. Degree M.A. or higher What is the total number of people living in your household? ___________ Source of Family Income: Employment Public Assistance Other__________________ In case of an emergency, provide the name of a person other than the one(s) listed above whom we could contact. Name: ____________________________________ Telephone Number: _____________________ Relation to Student: ____________________________________________________
1. Applicants must live and/or attend school in the Borough of Manhattan. 2. Applicants must attach the following 2 documents with their application. Applications will NOT be reviewed without these documents.
DOCUMENT 1 A copy of parent's or guardian's most recent signed Federal Income Tax Return-Form 1040 (all pages) or a public assistance budget letter.	DOCUMENT 2 A copy of student's most recent Report Card or Transcript with numerical grades.
3. Applications are reviewed three times a year. Applications must be submitted before the 15th day of the review month for the semester in which the applicant wishes to enroll.
Semester Fall (October-December) Spring (February-April) Summer (July-August)	Deadline September 15 January 15 May 15
By signing below, I certify that all of the information on this application and the attached documents are true and complete to the best of my knowledge. I give permission for the Columbia University Double Discovery Center (DDC) to consult and/or refer my child to a professional counselor when such counseling is deemed by the Center to be appropriate and to obtain full access to my child's academic records from school or the Board of Education to help my child with both academic work and college preparation. I also give permission to DDC to use my child's name and image, likeness, actions and statements in any live or recorded audio, video, or photographic display or other transmission, exhibition, or reproduction made by or on behalf of the Columbia DDC for promotion, illustration and advertising of the Double Discovery Center. Student's Signature: _____________________________________ Date: ____________ Parent's Signature: ______________________________________ Date: ____________

306 Lerner Hall Mail Code: 2604 2920 Broadway New York, NY 10027	Phone: (212) 854-3897 Fax: (212) 854-7457 E-mail: ddc@columbia.edu
Website: http://www.doublediscovery.org/ HOW TO GET TO THE DOUBLE DISCOVERY CENTER The Double Discovery Center is located on the third floor of Alfred Lerner Hall in Room W-306. The main entrance to Alfred Lerner Hall ( ) is located within the Columbia Campus, accessible through the first black gate at 115th Street & Broadway. The campus is accessible by train (1 or 9 to 116th Street and Broadway) or bus (M4, M60 or M104 to 116th Street and Broadway).