Student Intake form PART 2

1. What is your full name?

What is your full name? Name:

2. Do you think you will be able to afford to attend a:

	Yes	No
Public 4-year college or university	*Do you think you will be able to afford to attend a: Public 4-year college or university Yes	Public 4-year college or university No
2-year/community college	2-year/community college Yes	2-year/community college No

3. How difficult do you find the following subjects?

	Very Difficult	Somewhat Difficult	Not Difficult	Easy
Reading	*How difficult do you find the following subjects? Reading Very Difficult	Reading Somewhat Difficult	Reading Not Difficult	Reading Easy
Writing	Writing Very Difficult	Writing Somewhat Difficult	Writing Not Difficult	Writing Easy
Math	Math Very Difficult	Math Somewhat Difficult	Math Not Difficult	Math Easy
Science	Science Very Difficult	Science Somewhat Difficult	Science Not Difficult	Science Easy
Social Studies	Social Studies Very Difficult	Social Studies Somewhat Difficult	Social Studies Not Difficult	Social Studies Easy

4. Please rank each of the following activities we could provide you this school year:

	1 Not helpful at all	2	3	4	5 Most helpful
Tutoring/Homework Assistance	*Please rank each of the following activities we could provide you this school year: Tutoring/Homework Assistance 1 Not helpful at all	Tutoring/Homework Assistance 2	Tutoring/Homework Assistance 3	Tutoring/Homework Assistance 4	Tutoring/Homework Assistance 5 Most helpful
Reading support	Reading support 1 Not helpful at all	Reading support 2	Reading support 3	Reading support 4	Reading support 5 Most helpful
Help in organization, time management, and study skills	Help in organization, time management, and study skills 1 Not helpful at all	Help in organization, time management, and study skills 2	Help in organization, time management, and study skills 3	Help in organization, time management, and study skills 4	Help in organization, time management, and study skills 5 Most helpful
GEAR UP meetings at school	GEAR UP meetings at school 1 Not helpful at all	GEAR UP meetings at school 2	GEAR UP meetings at school 3	GEAR UP meetings at school 4	GEAR UP meetings at school 5 Most helpful
Individual meetings with GEAR UP staff	Individual meetings with GEAR UP staff 1 Not helpful at all	Individual meetings with GEAR UP staff 2	Individual meetings with GEAR UP staff 3	Individual meetings with GEAR UP staff 4	Individual meetings with GEAR UP staff 5 Most helpful
Enrichment activities (for example, Robotics, Saturday Academies, Book Clubs)	Enrichment activities (for example, Robotics, Saturday Academies, Book Clubs) 1 Not helpful at all	Enrichment activities (for example, Robotics, Saturday Academies, Book Clubs) 2	Enrichment activities (for example, Robotics, Saturday Academies, Book Clubs) 3	Enrichment activities (for example, Robotics, Saturday Academies, Book Clubs) 4	Enrichment activities (for example, Robotics, Saturday Academies, Book Clubs) 5 Most helpful

5. Please rank each of the following activities that will help you get ready for college.

	1 Not helpful at all	2	3	4	5 Most helpful
Academic plan/advising	*Please rank each of the following activities that will help you get ready for college. Academic plan/advising 1 Not helpful at all	Academic plan/advising 2	Academic plan/advising 3	Academic plan/advising 4	Academic plan/advising 5 Most helpful
Information on how to get into college	Information on how to get into college 1 Not helpful at all	Information on how to get into college 2	Information on how to get into college 3	Information on how to get into college 4	Information on how to get into college 5 Most helpful
Information on how to pay for college	Information on how to pay for college 1 Not helpful at all	Information on how to pay for college 2	Information on how to pay for college 3	Information on how to pay for college 4	Information on how to pay for college 5 Most helpful
College campus visits	College campus visits 1 Not helpful at all	College campus visits 2	College campus visits 3	College campus visits 4	College campus visits 5 Most helpful
Career exploration and advising	Career exploration and advising 1 Not helpful at all	Career exploration and advising 2	Career exploration and advising 3	Career exploration and advising 4	Career exploration and advising 5 Most helpful

6. IF you are a junior or senior in highschool:

	Yes	No
Have you taken the ACT?	*IF you are a junior or senior in highschool: Have you taken the ACT? Yes	Have you taken the ACT? No
Have you completed the FAFSA?	Have you completed the FAFSA? Yes	Have you completed the FAFSA? No

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