HEOP Program Student Support HEOP Program HEOP2023 Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields APPLICATION Select Status* New Student Readmit Student Transfer Student Student's First Name* Student's Last Name* Maiden Name CWID Address* Address Line 1 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code E-mail* Student's Cell Phone* Student's Home Phone Number Date of Birth* https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Gender* Female Male Non-Binary Marital Status* Single Married Separated Divorced Widowed Race* Black/ African American Hispanic/Latino Caucasian Asian American Indian/ Alaska Native Native Hawaiian/Pacific Islander Citizenship Status* U.S. Permanent Resident Alien Registration Country of Birth, if not United States Native Language* Are you physically handicapped?* Yes No Nature of disability Have you been diagnosed as learning disabled?* Yes No When In case of Emergency contact* Phone* Relationship* Address* Address Line 1 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code EDUCATIONAL BACKGROUND Do you have a High School Diploma* Yes No Do you have a GED* Yes No List High School Attended 1* Address* City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code List High School Attended 2 Address City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code If applicable, list the college(s), business schools, nursing schools, and vocational schools beyond high school you attended before/after coming to Mercy College. School Name Address City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State School Name Address City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State Were you in an opportunity program at a prior institution? If yes, please check program. EOP SEEK HEOP College Discovery Please check if you have been in any of the following programs: My Brother’s Keeper (MBK) Early College High School(ECHS) Science and Technology Entry Program (STEP) Liberty Partnerships Program (LPP) Foster Youth College Student Initiative (FYCSI) NYS Pathways in Technology Early College High School (P-Tech) CUNY Early College Initiative (ECI) Trio Upward Bound McNair Household Information Total number of people living in your household, including yourself* Please list full name, age and relationship to you of all members of your household. Also, indicate if person works or attends college.* Ex: Robert Brown, 32, brother, attends college Do you meet any of the following conditions? Have children whom you support Were born before January 1, 2000 Are in a legal guardianship Are an orphan or ward of the court A veteran of the Armed Services who was engaged in active duty Parents' Marital Status* Married Not Married but living together Divorced Separated One is Widowed Both are deceased Unknown/Other Are both parents U.S citizens, nationals, or legal residents?* Yes No If not, please explain Did either of your parent(s) graduate from college?* Yes No Were you a legal New York State resident before January 1, 2021 and do you remain so?* Yes No Were your parent(s) New York State resident(s) before January 1, 2021 and do they remain so?* Yes No If not, please explain Have you taken part in another HEOP summer program, taken college-level courses, either at a college or through a high school program, or have you matriculated at any institution of higher education?* Yes No If yes, please explain Income Information Parent/Guardian's (with whom you reside) total income in 2021 (including wages, SSI, disability, unemployment)* Did the parent(s) you reside with file taxes in 2021?* Yes No If not, please explain Were you claimed on your parent(s) or anyone's taxes in 2021?* Yes No If yes, who claimed you? Student's total income in 2021 (including wages, SSI, disability, unemployment)* Does anyone in your household receive child support?* Yes No If yes, what was the total amount received for ALL children in the household in 2021? Check all that apply Food Stamps Rent/Shelter Disability Medicaid Supplemental Security Income Are there any special circumstances you wish to share regarding your financial situation? Yes No ***Enclose additional information to explain special circumstances like medical costs, mismanagement of income, etc.*** I certify that all information provided in this application is accurate to the best of my knowledge. Student's Signature [clear] Use your mouse or finger to draw your signature above Date/Time https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Virtual Interview Form for Freshmen Why did you decide to go to college?* When did you make the decision to go to college?* Whose decision was it that you go to college?* My own My parents/family Other: Other Value What do your parents/family members and friends think about you coming to college?* Do you work?* Yes No If yes, what is your job and how often do you work? Do you have children?* Yes No If yes, How many? Have you made arrangements between work, school, & family?* Yes No Was Mercy College your first choice? Yes No How do you feel about coming to Mercy College as opposed to other colleges or universities?* Do you know what the tuition is at Mercy?* Yes No How did you find out? What is the tuition at Mercy? Did you file the FAFSA?* Yes No Did you file a TAP application?* Yes No Where do you spend your time outside of school?* What is the highest level of education you would like to attain?* No specific plans Associate degree Bachelor's degree Graduate degree What are you interested in studying?* How long do you think it would take you to graduate?* What do you think you will enjoy the most about coming to college?* Did you have any problems with school attendance in the past? If so, explain. * What are your study habits?* Do you have any fears or anxieties about going to college?* How did you hear about HEOP?* What are your expectations of HEOP? * Are you registered to vote?* Yes No Are you politically active?* Yes No As a HEOP student you must participate in the following activities: Lobby Day/Letter Writing Campaign, Leadership Conference, General Meetings. Are you willing to sacrifice some time to participate in these activities?* Yes No Why Yes or No? What short term goals do you have? * What long term goals do you have?* Statement of Understanding The undersigned applicant understands that to be considered for the Higher Education Opportunity Program at Mercy College, I need to submit all the required documentation and I am aware of the following (please check to acknowledge): Checkbox* I understand that I must be financially and academically eligible for the Program as outlined by New York State and Mercy College, and as evidenced by my documentation. I understand that for entrance in 2023-24 year, documentation for 2021 will be requested (this may include: W2's, federal and state taxes, other tax documentation such as Form 1099, tax transcripts, etc.) I must send the required documentation, as pertains to my case and as requested by Mercy HEOP, to be eligible. I must be a New York State resident. If a dependent, my parent whom I reside with and/or who claims me for tax purposes must be a New York State resident. I must apply for and be eligible for Federal Financial Aid (FAFSA). I must apply for and be eligible for the New York State Tuition Program (TAP). I must be a high school graduate by June 30, 2023. I must attend and successfully complete the HEOP Pre-Freshman Summer Program (Summer 2023). I understand that a final decision and entrance into the program is contingent on these requirements being met and verified through the proper documentation. The HEOP Program may request any documents which are necessary to prove eligibility. I understand that falsifying or providing misleading information is grounds for removal from the program and the college, if an offer of admission is made. If the discovery of fraudulent information occurs after entrance, a student may be removed and required to pay back funds already received. Student Signature [clear] Use your mouse or finger to draw your signature above Date https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Previous← Next→ Progress Formstack Online Forms Enter your save and resume password Cancel Confirm