California State University, Bakersfield College Assistance Migrant Program

Application for Admission

Our Mission “to serve, educate and empower migrant and farm-working families”

9001 Stockdale Highway 70 LOR Bakersfield, CA 93311-1022

Main: 661-654-3212 Fax: 661-654-6521

www.csub.edu/camp

CHECKLIST

Instructions: The CAMP program application for admission must be typed, saved as PDF, and sent via email to your CAMP Outreach Advisor. Contact us for assistance in collecting any of the documents listed below.

Contact Information Erika Madrigal; (661) 654-2759 / emadrigal2@csub.edu Maricela Ramirez; (661) 654-6121 / mramirez@csub.edu www.csub.edu/camp

DOCUMENTS ATTENTION

☐ Application for Admission June 1, 2020 ☐ Personal Statement (priority deadline)

☐ Consent for Release of Information

☐ Recommendation Form (2)

☐ High School Transcript (unofficial)

☐ Test Score Report (i.e. SAT, ACT, ACT Residual Test)

☐ FAFSA Student Aid Report (SAR) or California Aid Report (CAR)

☐ Eligibility (one document must be submitted to confirm eligibility)☐ Seasonal Farmwork Employment☐ Employment Verification Form☐ Proof of seasonal farmwork employment (i.e. check stubs/W-2)

OR ☐ Migrant Education; Certificate of Eligibility (COE)

OR ☐ Certificate of Workforce Investment Act (WIA)

MANDATORY EVENTS

Due to the COVID-19 Pandemic, the dates for the mandatory events are tentative and will be confirmed at a later date.

IMPORTANT DATES

☐ Celebrate CAMP (must attend one Celebrate CAMP session)☐ Celebrate CAMP 1 (student and parent(s) orientation) August 6, 2020

☐ Celebrate CAMP 2 (student and parent(s) orientation) August 7, 2020

☐ CAMP Summer Bridge Program August 17th – August 22nd CAMP scholars are required to attend the CAMP Summer Bridge Program.

☐ High School Equivalency Program (HEP)Check the box if your parent(s) will be joining the HEP program. Student’sparent(s) who join the program will be given priority for admission to theCAMP program. For more information on HEP visit www.csub.edu/hep

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California State University, Bakersfield College Assistance Migrant Program

Application for Admission

PERSONAL INFORMATION

Name of student: First Name Middle Name Last Name

Date of birth: Gender: ☐F ☐M mm/dd/yyyy Age

Place of birth: City State County

Residency status: ☐U.S. Citizen ☐Permanent Resident ☐Other:

Ethnic background: ☐African-American ☐Filipino

☐Anglo-American☐Hispanic/Latino

☐Asian-Pacific Islander☐Native American Indian☐Other:

Home address: Number & Street City State Zip Code

Mailing address: (if different)

Number & Street City State Zip Code

Contact information: Cell Email T-shirt Size

FAMILY INFORMATION

Provide your father’s contact information: Cell phone # Home Phone # Preferred Language

Provide your mother’s contact information: Cell phone # Home Phone # Preferred Language

Has your father performed seasonal farmwork employment in the last 24 months? ☐Yes ☐No

Name of Company Dates (mm/yyyy to mm/yyyy) Has your mother performed seasonal farmwork employment in the last 24 months? ☐Yes ☐No

Name of Company Dates (mm/yyyy to mm/yyyy)

What is your annual family/household income? Family household size:

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List the family members who live with you (immediate family only) U.S. Education only Name Age Relationship Highest grade

level completed Completed HS Diploma/GED

College Degree

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ACADEMIC INFORMATION

Last high school attended: Name City State

Graduation date: mm/yyyy GPA

Are you a current/former participant of the Migrant Education Program? ☐Yes ☐No

If yes, participation took place during: ☐High School ☐Middle School ☐Elementary School

Have you earned college credits prior to graduating high school? ☐Yes ☐No

If yes, name of college/university:

This upcoming Fall will you be a college transfer student? ☐Yes ☐No

Will you be the first child in your family to attend college? ☐Yes ☐No

Have you applied to CSU, Bakersfield? ☐Yes ☐No

If yes, provide student ID: If so, have you been accepted to CSU, Bakersfield? ☐Yes ☐No

Have you been accepted to the following program(s)? ☐EOP ☐Other:

How will you commute to campus? ☐Own transportation ☐Getting dropped off☐Public transportation ☐Carpooling ☐Other:

REFERENCES Must provide the names and emails of two references, current or former teachers, counselors, etc. Your references will receive the recommendation form via email to complete. Request approval prior to listing their information.

Name of reference: School email:

Name of reference: School email:

STATEMENT OF ACCURACY By signing below, I hereby certify that all statements made on this application and all other documents submitted in support of my Application for Admission are true and complete to the best of my knowledge. I understand that it may be necessary for CAMP staff to obtain additional records from other CSUB departments in order to verify my current academic and financial aid status. I grant permission for such records to be requested and reviewed.

Signature of student: Date:

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PERSONAL STATEMENT To receive a higher consideration for admission to the program, you must answer the following questions. Your statement to these questions will be evaluated to determine your admission and need for CAMP services.

1. Explain your life experience as a migrant student or as a child of a farm-working family. How has thisexperience influenced your life today?

2.What is the main challenge(s) you need assistance in overcoming? And how can the program assist you toovercome such challenge(s)?

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3. What is one personal characteristic you possess that you and your parent(s) value and one that you need to workon for yourself?

4. During the first-academic year (Fall/Spring), the program requires CAMP Scholars to complete two importantelements that have helped students successfully complete 24-units or more in one academic year:(1) Five Lab/Tutoring Hours on a weekly basis and (2) CAMP course enrollment. Please explain how youwill adjust your time to complete these requirements and how it will be beneficial to you?

College Assistance Migrant Program California State University, Bakersfield 9001 Stockdale Highway 70 LOR Bakersfield, CA 93311-1022 Main: 661-654-3212 Fax: 661-654-6521

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CONSENT FOR RELEASE OF INFORMATION

Name of applicant: First Name Middle Name Last Name

Date of birth: Phone number: mm/dd/yyyy

I, the undesignated, authorize the entity mentioned below to release the information requested from my records. To assist with the documentation of eligibility to receive services from the College Assistance Migrant Program (CAMP), U.S. Department of Education – Office of Migrant Education.

This authorization shall remain effective during my participation in the College Assistance Migrant Program at California State University, Bakersfield or until revoked in writing.

Signature of applicant: Date:

The section below is to be completed by CAMP staff (only):

Name of entity: Phone number:

Address: Number & Street City State Zip Code

Select all that apply:

☐Migrant Education Program – Copy of Certificate of Eligibility

☐High School Transcript

☐Employment Dates

☐Job duties

☐Term of Position (seasonal or permanent)

☐Other Explain:

College Assistance Migrant Program California State University, Bakersfield 9001 Stockdale Highway 70 LOR Bakersfield, CA 93311-1022 Main: 661-654-3212 Fax: 661-654-6521

EMPLOYMENT VERIFICATION FORM

This is a request for employment verification for the employee mentioned below. The employee or employee’s family member have applied for academic support services to the College Assistance Migrant Program (CAMP) at California State University, Bakersfield. In order to be eligible for services by the CAMP program, under the guidelines established by the U.S. Department of Education, a student who themselves or whose immediate family must have worked at least 75 days within the last two years in agriculture as a migrant or seasonal agricultural worker. This includes any activity directly related to the production crops, dairy products, poultry, or livestock for sale or personal subsistence, cultivation or harvesting of trees, or fish farms. The purpose of this form is to request your certification of the type of work and type of employment your current/former “employee” performed.

Name of student: First Name Middle Name Last Name

Name of employee: First Name Middle Name Last Name

The section below is to be completed by the employer or authorized staff (only):

Name of company/employer:

Name of supervisor:

Employer’s address: Number & Street City State Zip Code

Phone number: Fax number:

Dates of employment: to mm/dd/yyyy mm/dd/yyyy

Type of employment (check one): ☐Seasonal ☐Permanent

Type of work performed by the employee:

I certify that the information provided above is completed and accurate according to the employee’s record.

Name of staff: Title of staff:

Signature of staff: Date:

Attention: Please return this form back to employee or return via email to camp@csub.edu. Thank you!