Program Application

Apply for the program of your choice

Program Application – PACT, Inc.

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Which School Do You Attend?

Choose Your School:*

Ernest Kimme High School

Jesse Bethel High School

Richmond High School

Solano Widenmann Leadership Academy

Vacaville High School

Vallejo High School

Will C Wood High School

Other

Which Program Are You Interested In?

Choose a Vallejo Program:*

Read more about Educational Talent Search here.

Educational Talent Search

Vallejo Upward Bound

Middle School Program:*

Educational Talent Search

Choose a Program:*

Educational Talent Search

Vallejo Upward Bound

Vacaville Upward Bound

Vacaville Program:*

Vacaville Upward Bound

Richmond Program:*

Educational Talent Search

You can read more about each PACT program here:

Educational Talent Search
Vallejo Upward Bound
Vacaville Upward Bound

Student's Information:

Student's First and Last Name*

First Last

Gender*

Female

Male

Other

Age*

Date of Birth*

MM slash DD slash YYYY

Ethnicity (Report All)*

Hispanic/Latino of any race

American Indian or Alaska Native, non-Hispanic/Latino

Asian, non-Hispanic/Latino

Black or African American, non-Hispanic/Latino

White, non-Hispanic/Latino

Native Hawaiian or Other Pacific Islander, non-Hispanic/Latino

Two or more races, non-Hispanic/Latino

Race or Ethnicity Unknown

Student's Personal Email

Student Cell #*

Student Home #

Address (Include City/State/Zip)*

Street Address Address Line 2 City State ZIP Code

Grade Level*

Attach your school transcript here:

Max. file size: 512 MB.

Citizenship Status*

U.S. Citizen

Permanent Resident

Other

Lives With*

Mother

Father

Both

Guardian

Former/Current Foster Youth or Ward of Court?*

Yes

Homeless or Displaced Youth?**

Yes

Student Needs Assessment

Educational Goal*

Which goal best describes your present plan after graduating from high school? (please check one):

To attend a community college & earn an AA/AS Degree

To attend community college & transfer to a 4-year university

To attend a 4-year college & earn a BA/BS Degree

To complete a technical/vocational program

To work full-time

To enter the military service

Undecided

Student Needs Assessment

Please check the service you feel you need (check all that apply):

College Admissions Advising

Career Exploration

Leadership Development Workshops

Financial Aid Advising

SAT/ACT Information

SAT Preparation Workshop

College Campus Visit

Scholarship Information

Essay Writing Skills

College Survey

Name 2 majors/careers you would be interested in:

What colleges would you be interested in applying to? (Check all that apply):

Berkeley

Davis

Irvine

Merced

Riverside

Santa Barbara

Santa Cruz

San Diego

CSU

SFSU

SJSU

East Bay

Sacramento

Cal Poly SLO

San Diego

Sonoma

City College of San Francisco

Skyline College

College of San Mateo

Laney College

Diablo Valley College

Private

USF

University of the Pacific

Santa Clara University

Dominican University

St. Mary’s College

Other

How did you learn about PACT, Inc?

Presentation

Teacher

Counselor

Friend

School Announcement

Other, please specify:

Parent/Guardian Information:

Parent/Guardian Name (First & Last)*

First Last

Parent/Guardian Status*

Single

Married

Separated

Divorced

Parent/Guardian Cell #*

Parent/Guardian Home #

Parent/Guardian Work #

Parent/Guardian Email

Did Either Parent Receive a Bachelor's Degree (4-Year College Degree)?*

Yes

Total Family Income (Yearly)*

(See line 43 on Tax Form 1040, line 27 on Form 1040A, or line 6 on Form 1040EZ). If parents are separated, this should be completed by the parent whom the student lives with or by the parent/guardian providing at least 50% of student’s financial support).

# of People in the Household*

Consent*

I agree to the submission of this application.

I authorize PACT, Inc. to obtain copies of my student’s report cards, transcripts, test scores, and other academic information to provide him/her/myself with academic advising. I grant permission for my student to participate in-person and/or via Zoom, Google Hangouts, Google Classroom, Facebook, Instagram, or other virtual/online/social platforms for program purposes. I hereby give permission for images of my child/self captured during program events through video, photo, and digital camera to be used solely for the purposes of PACT, Inc. promotional materials (e.g., brochures, newsletters) and waive any rights of compensation or ownership thereto.

I confirm that all the information in this application is true and has been verified by my signature below.

Parent/Guardian Signature*

A parent/guardian signature is required for any students under 18-years-old.

Student Signature

Date*

MM slash DD slash YYYY

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