Elevate Program Enrollment Form - Catholic Charities of Baltimore

Applicant Information

Name*

First Middle Last

Date of Birth*

Student ID Number*

Contact Information

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

May we text you?*

Yes
No

Alternate Phone

Email*

Preferred language*

Communication assistance required?*

Yes
No

Emergency Contact Information

Name*

First Last

Relationship*

Contact Phone*

Questions

At which CCBC campus would you like to receive services?*

Catonsville
Dundalk
Essex

Are you graduating or transferring this semester?*

Yes
No

Are you receiving the Federal Pell Grant?*

Yes
No

(We will need to verify this information visually.)

Are you taking at least six credits this semester?*

Yes
No

Is your cumulative GPA at least 2.0?*

Yes
No

How many total credits have you accumulated at CCBC as of the time of this application?*

Demographic Information

Gender*

Male
Female
Other

Marital Status*

Single (never married)
Married/domestic partnership
Widowed
Divorced
Separated

Race/Ethnicity*

Black/African American
White/Caucasian
Asian (not Pacific Islander)
Hispanic/Latino(a)
American Indian/Native Alaskan
Hawaiian Native/Pacific Islander
Other

Are you currently emplyed?*

Yes
No

Employment Status

FT
PT
Temp FT
Temp PT

Military Veteran/Actively Serving*

Yes
No

Do you have children of your own ages 0-17 who reside in your household?*

Yes
No

If yes, complete each that applies in the following questions.

Number of biological children in household

Number of adopted children in household

Number of foster/temporary custody children in household

Do you have children of your own ages 0-17 who reside outside of your household?*

Yes
No

If yes, complete each that applies in the following questions.

Number of biological children outside of household

Number of adopted children outside of household

Number of foster/temporary custody children outside of household