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Rising Scholars Intake Form

The information below is confidential and only viewed by the rising scholar program staff. If you need assistance completing this form either in person or virtually, don't hesitate to contact us at risingscholars@glendale.edu or call us at 818-240-1000 ext. 5580.  
Please correct the fields below:

First Name
 *
Last Name
 *
Phone Number
 *
What is your email address?
Which semesters do you wish to attend Glendale Community College?
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Which semesters do you wish to attend Glendale Community College?
To serve you better, which of the following best describes you?
To serve you better, which of the following best describes you?
If you are currently incarcerated, what is your expected release date and county of parole?
 *
Do you need assistance with any of the following services offered by Glendale Community College:  
Do you need assistance with any of the following services offered by Glendale Community College:

Do you need assistance with any of the following services offered by the Department of Rehabilitation (DOR):  

Do you need assistance with any of the following services offered by the Department of Rehabilitation (DOR):
Do you need assistance with any of the following services offered off-campus by our Community Partners:  
Do you need assistance with any of the following services offered off-campus by our Community Partners:
Do you need to register with law enforcement authorities or any registry?
Do you need to register with law enforcement authorities or any registry?
Do you have a:
 *
Do you have a:
Have you previously attended any other colleges?
 *
Have you previously attended any other colleges?
What is your major? If you don't know yet, please type "undecided" in the box below.
Have you completed any transferrable units?
 *
Have you completed any transferrable units?
Were you referred by someone or an organization to our program? 
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Were you referred by someone or an organization to our program?
Have you received services or are you interested in learning more about services for a disability or other diagnosis (examples, learning disability, ADHD, verified medical condition, verified mental health diagnosis, etc.).
 *
Have you received services or are you interested in learning more about services for a disability or other diagnosis (examples, learning disability, ADHD, verified medical condition, verified mental health diagnosis, etc.).
Have you completed the financial aid (FAFSA) application or the California Dream Act Application (This is the state of California's financial aid for our undocumented students)?
Have you completed the financial aid (FAFSA) application or the California Dream Act Application (This is the state of California's financial aid for our undocumented students)?
Do you receive Cal Fresh (Food stamps)?
Do you receive Cal Fresh (Food stamps)?
If no, do you need help applying for Cal Fresh?
If no, do you need help applying for Cal Fresh?
Do you need help applying for Medi-Cal or Medicare?
Do you need help applying for Medi-Cal or Medicare?

If you have any other concerns or comments, please type it in the box below.

  1. To receive a copy of your submission, please fill out your email address below and submit.