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NOTE: Two short answer responses are required for this application. You will not be able to save the application and return to it later. We suggest you write your short answer response in a word document and then copy and paste in to this application.

STUDENT DEMOGRAPHICS AND CONTACT INFORMATION

Name * First Last

Did you speak to an Expanded Horizons staff before applying? *
Yes No

How did you hear about our program? *
My school A family member Social Media (Instagram/LinkedIn) A peer or friend Henry Street Settlement website Henry Street Settlement staff member Athletics at Henry Street Settlement Other

Do you live on the Lower East Side? *
Yes No

If no, what neighborhood do you live in?

Do you live in a NYCHA Building or Development? *
Yes No I don't know

Permanent Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Personal Email *

Student Cell Phone Number * ### - ### - ####

Gender *
Male Female Other gender identity

Gender Pronouns (You may choose more than one) *
She/Her/Hers He/Him/His They/Them/Theirs Other

Date of Birth * MM / DD / YYYY

Ethnicity (Check All That Apply) *
Black/African American Asian/Pacific Islander Latino/a Native American White (non-Latino/a) Other

If you checked other please list here:

What is the primary language spoken at home? *

Do you attend high school on the Lower East Side?
Yes No

Current High School you are attending (please type out full name): *

Current Grade: *

Name of Guidance/College Counselor *

Guidance/College Counselor E-Mail *

Do you currently have an IEP (individualized education program)?

Will you be the first in your immediate family to go college? (Immediate family is just parents and siblings.) *

Highest level of Education completed by Parent/Legal Guardian *

Gross Household Income (before taxes): *

Number of people in household (including you) : *

Who pays for rent, utilities, and food in your household? *

Is your family receiving public assistance?(SNAP, Disability Insurance, Housing assistance, Medicaid, etc...) *

Are either of your parents or guardians who live with you receiving Disability Income? *

Do you have medical insurance ? *

Medical Insurance Name/Company: *

Insurance Member ID Number (Usually on your Insurance Card) *

PARENT/LEGAL GUARDIAN CONTACT INFORMATION

Parent/Guardian 1 Name * First Last

Parent/Guardian 1 Phone Number * ### - ### - ####

Parent/Guardian 1 Email Address *

Parent/Guardian 1's Job (If they're not working, put Unemployed.) *

Do you live with Parent/Guardian 1? *
Yes No Sometimes

Parent/Guardian 2 Name First Last

Parent/Guardian 2 Phone Number ### - ### - ####

Parent/Guardian 2 Email Address

Parent/Guardian 2's Job (If they're not working, put Unemployed.)

Do you live with Parent/Guardian 2?
Yes No Sometimes

If you don't live with either parents or legal guardians, who do you live with that is an adult caretaker?

Do either of your parents own a home in the United States? *
Yes No I don't know

Who is your Emergency Contact? *
Parent/Guardian 1 Parent/Guardian 2 Other

If you selected OTHER, who is your emergency contact? Include Name and Number.

STUDENT ACADEMIC PROFILE

What is your most recent overall GPA or current GPA? (As listed on your transcript.) *

What is your grade in your most recent English or Literature class? *

What is your grade in your most recent Math class? *

Do you have your own working laptop or desktop computer that you can use whenever you need? *
Yes, I have a laptop Yes, I have a desktop computer No, I have neither No, but my school lends me one Not yet, but I will soon

How many clubs or extracurricular activities are you in right now? (In or outside of school) *

Are you currently in any other college readiness programs? *
Yes No Unsure

Can you attend in-person afterschool classes at Expanded Horizons at least once a week for every academic year? *
Yes No Maybe

SHORT ANSWER QUESTIONS

*We encourage you to write your responses in a word doc and copy and paste it here when you are ready to submit*

Short Answer Question 1

Please explain why you want to be in Henry Street Settlement's college readiness program, Expanded Horizons. (Between 150 - 250 words) *
Enter 150 to 250 words. Currently Used: 0 words.

Short Answer Question 2

What do you hope to gain from this program that is NOT related to college readiness? This can be anything! (Max 200 words) *
Maximum of 200 words. Currently Used: 0 words.

As the applicant, I also am willing, able, and eager to participate in the Henry Street Settlement Expanded Horizons College Success Program. If I am selected, I will be an active member of the program and understand I must attend programming AT LEAST 80% of the time. In addition, I will respect my peers, counselors, and ALL staff. I understand that this program requires a commitment, and I am prepared to meet all program standards. *
I understand

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